xanidis, nikos (2018) exploring the implementation of cognitive...
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Xanidis, Nikos (2018) Exploring the implementation of Cognitive
Behavioural Therapy for psychosis (CBTp) using the Normalisation Process
Theory (NPT) framework. D Clin Psy thesis.
https://theses.gla.ac.uk/30812/
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Enlighten: Theses
https://theses.gla.ac.uk/
Exploring the implementation of Cognitive Behavioural Therapy for psychosis
(CBTp), using the Normalisation Process Theory (NPT) framework
And Clinical Research Portfolio
Nikos Xanidis
BSc (Honours), MSc
Submitted in partial fulfilment of the requirements for the degree of
Doctorate in Clinical Psychology
Institute of Health and Wellbeing
College of Medical, Veterinary and Life Sciences
University of Glasgow
September 2018
Acknowledgments
I would like to thank sincerely the professionals who participated in this study and were
willing to share their experiences and views. Many thanks also to Dr. Everett Jylyan and Dr.
Peter Ronald for their assistance with recruitment. Many thanks to the independent raters who
provided their ratings and increased the reliability of my findings.
Thank you, Professor Andrew Gumley, for the support, guidance and learning experience
throughout this project. I appreciate your optimism and encouragement during this project. I
am grateful for our collaboration on this project.
I would also like to thank my placement supervisors Dr. Julie Bennett and Dr. Susan
O’Connell for their support and understanding.
Special thanks to my parents Iolanta and George, my brother Anestis, my partner Foteini and
my friends, Kiki, Giota, Ciara, Dave, Vaios and Demmi for the emotional support and
believing in me throughout this project.
Table of Contents Chapter One: Systematic Review ........................................................................................................ 1
Abstract ............................................................................................................................................... 2
Introduction ......................................................................................................................................... 3
Methods .............................................................................................................................................. 5
Results ................................................................................................................................................. 8
Discussion ......................................................................................................................................... 24
References ......................................................................................................................................... 28
Chapter two: Major Research Project .............................................................................................. 33
Plain English Summary ..................................................................................................................... 34
Abstract ............................................................................................................................................. 36
Introduction ....................................................................................................................................... 37
Methods ............................................................................................................................................ 40
Results ............................................................................................................................................... 43
Discussion ......................................................................................................................................... 54
References ......................................................................................................................................... 60
Appendices ........................................................................................................................................... 65
Appendix 1.1: Journal Submission Guidelines ................................................................................. 65
Appendix 1.2: Quality Appraisal of included studies ....................................................................... 70
Appendix 1.3: List of overarching themes ........................................................................................ 72
Appendix 1.4: Walsh & Downe (2006) Quality Appraisal Framework ........................................... 75
Appendix 1.5: Search terms for Systematic Review ........................................................................ 80
Appendix 2.1 Major Research Project Proposal ............................................................................... 82
Appendix 2.2: Rationale for amendments to initial research proposal ............................................. 96
Appendix 2.3: MVLS ethics committee approval............................................................................. 97
Appendix 2.4: Research and Development Department Approval ................................................... 98
Appendix 2.5: Amendments approval from R&D .......................................................................... 101
Appendix 2.6: Information leaflet ................................................................................................... 102
Appendix 2.7: Participant Information Sheet ................................................................................. 103
Appendix 2.8: Interview Topic Guide ............................................................................................ 108
Appendix 2.9: A list of the overarching themes ............................................................................. 109
Appendix 2.10: Consent Form ........................................................................................................ 111
Appendix 2.11: Sample of thematic analysis coding ...................................................................... 112
1
Chapter One: Systematic Review
The implementation of Cognitive Behavioural Therapy for psychosis drawing
on staff, service users and carers experiences: A meta-synthesis
Nikos Xanidis*
Submitted in partial fulfilment for the Doctorate of Clinical Psychology
(DClinpsy)
*Address for Correspondence: Academic Unit of Mental Health and Wellbeing, University of
Glasgow, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow, G12 0XY. E-mail:
Prepared in accordance with submission requirements for Psychology and Psychotherapy:
Theory, Research and Practice (see Appendix 1.1)
Word count including references: 7126
2
Abstract
Objectives: Despite the availability of national guidelines, evidence indicates limited
implementation of Cognitive Behavioural therapy for psychosis (CBTp). The aim of this
review was to identify and meta-synthesise current qualitative data regarding the experiences
and perspectives of key stakeholders in relation to the routine implementation of CBTp. The
meta-synthesis aimed to explore how key stakeholders make sense of the facilitators and the
barriers to CBTp implementation.
Method: Systematic searches of Psychinfo, Medline, Pubmed, CINAHL, EMBASE, were
completed up to March 2018. Examination of reference lists, citation searches, as well as,
hand search of the Clinical Psychology Forum supplemented the search strategy. The
methodological quality of the identified studies was also assessed. A meta-ethnography
approach guided the synthesis of the data.
Results: Eleven studies were analysed. Three overlapping themes, each consisting of two
subthemes were identified: difficulties in seeking treatment (motivation to engage, practical
difficulties), challenges of providing care (professionals’ confidence, practical challenges)
and service design (lack of resources, conflicting needs).
Conclusion: Findings indicated that difficulties in seeking, delivering and investing in CBTp
are interconnected. This suggests a systemic conceptualisation of successful implementation
of CBTp, which relies on the collaboration of all key stakeholders.
3
Introduction
Psychosis has a considerable impact on a person’s quality of life, with evidence suggesting
high rates of premature mortality and elevated levels of unemployment (Schizophrenia
Commission, 2012). Further evidence suggests that although anti-psychotic medication
improves symptoms, it results in a range of serious side effects including cardiovascular
complications (Foley & Morley, 2011) and acceptance of antipsychotic medication can be
poor. Additionally, even when people are on optimal doses of antipsychotic medication,
residual symptoms and relapse remains a significant problem (Lally, Gaughran, Timms &
Curran, 2016).
CBT for psychosis (CBTp) contributes to the reduction in symptoms (Turner, van der
Gaag, Karyotaki, & Cuipers, 2014) and it is also associated with reduced risk of transition to
psychosis for individuals with elevated risk (Hutton & Taylor, 2014). A systematic review of
qualitative studies of service users’ experiences of CBTp (Berry & Hayward 2011) reported
that the ingredients of CBTp such as normalisation and offering an explanation to their
symptoms were perceived as helpful in terms of the acceptance of symptoms. This was
associated with adopting more helpful coping strategies and a reduction in reported distress.
Similarly, Kilbride et al. (2013) reported that service users perceived normalisation and
shared decision as important aspects of CBTp in their recovery journey. Furthermore,
national guidelines, in the UK advise that CBTp should be offered to all individuals
experiencing psychosis over the course of at least 16 sessions (National Institute for Health
and Care Excellence; NICE, 2014).
Despite national guidelines recommending the use of CBTp, few individuals
experiencing psychosis have access to this (Schizophrenia Commission, 2012). Over the
recent years, studies have focused on exploring difficulties of implementing CBTp in routine
clinical practice. A systematic review of the literature by Berry and Haddock (2008) reported
4
that barriers to CBTp implementation involved factors related to recipients of the services
such as poor motivation, lack of family support and the severity of individuals’ symptoms.
Furthermore, a recent qualitative synthesis (Wood, Burke & Morrison, 2015) reported the
challenges that service users experienced to engage with CBTp, which involved difficulties
expressing emotions, managing distress and complying with homework assignments.
Additional factors which affected implementation were related to mental health
professionals’ reported lack of competence and pessimistic views on recovery in psychosis.
Organisational barriers consisted of a lack of investment in CBTp which translated into lack
of training, supervision and protected time for the implementation of CBTp (Berry &
Haddock, 2008). Ince, Haddock, and Tai (2016) reported that organisation barriers were the
most frequently reported in the literature followed by barriers related to professionals’ and
service recipients’ attitudes.
A recent pilot study (Fornells-Ambrojo, et al., 2017) identified the role of clinical
leadership (e.g. referral pathways, training, staff awareness, protected time) as crucial in
CBTp implementation. Previous systematic reviews (e.g. Berry & Haddock, 2008; Ince et al.,
2016) have described various barriers and facilitators to the CBTp implementation, without
however attempting to synthesise and interpret qualitative data. Additionally, the data that
were used were primarily related to professionals’ experiences and views of CBTp.
Systematic reviews of qualitative research have focused solely on service users’ experiences
of receiving CBTp without attempting to synthesise implementation from a range of
stakeholders’ perspectives.
Aim
The aim of this systematic review was to identify and meta-synthesise current qualitative
research investigating the experiences and perspectives of key stakeholders (including where
5
available mental health staff, service users, families and carers) in relation to the routine
implementation of CBTp. This review will answer the following question: How do
stakeholders experience/make sense of the facilitators and barriers to the implementation of
CBTp?
Methods
Search Strategy
Before initiating the search, databases were searched for any existing reviews. No existing
meta-syntheses of qualitative studies which explored the implementation of CBTp were
identified. The main search strategy for this study included searching electronic databases
(Psychinfo, Medline, Pubmed, CINAHL, and EMBASE), checking reference and citation
lists of the included studies. A subject librarian was consulted on the development of the
search strategy used. Boolean operators (OR and AND) were used to combine search strings.
Title, abstract and keyword searches using the following terms were run (Appendix 1.5). The
terms were tested to ensure that no problems with missing potential eligible papers were
identified (e.g. the American spelling “behaviour”; “behavioral” did not increase the number
of the final eligible papers)
1. Cognitive Behavioural Therapy or CBT or CBTp or Cognitive Behaviour Therapy
AND
2. Schizophren* or Psychos*
AND
3. NICE or “National Institute for Health and Care Excellence” or guideline* or
Implement*
The search was carried out up to March 2018. Clinical Psychology Forum articles were
also hand searched as previous systematic reviews have identified mixed methods audit
reports which were relevant to the study’s aims. The reference list of a previous qualitative
6
synthesis review (Berry & Hayward, 2011) was also hand searched for any relevant papers
and to improve the sensitivity of the search strategy.
Inclusion and exclusion criteria
The following inclusion criteria were employed: Studies i) with adult population with a
diagnosis of schizophrenia / psychotic symptoms/ experiences or individuals who had contact
with this group (mental health staff, policymakers, carers), ii) including primary research
information on the experience/perspective of stakeholders regarding the implementation of
CBTp and/or CBT for people with psychosis, iii) in English language, iv) with full text
available, v) which use qualitative methods (e.g. qualitative studies or mixed methods
studies) , vi) quotations/excerpts reported, vii) published between the years 2002 to 2018.
Exclusion criteria included: i) studies not focusing on experiences of implementation of
CBTp or CBT for people with psychosis, ii) studies not employing any qualitative
methodology, iii) participants not having experienced psychotic symptoms, iv) absence of
verbatim quotations being reported.
Inclusion and exclusion criteria were used to review the studies that were identified
by this search. Initially, studies’ titles were reviewed. Titles that were not meeting the
inclusion criteria were excluded. Following this, the abstracts of the remaining studies were
reviewed. Only studies whose abstracts indicated that the inclusion criteria were met, were
reviewed by reading the full article.
Reflexivity
At the time of this systematic review, the lead researcher was conducting a qualitative study
which aimed to explore the implementation of CBTp based on mental health professionals’
7
perspectives. Moreover, the researcher had used CBTp in their clinical practice. This might
have influenced the researcher’s interpretation of the themes generated from the selected
studies. Additionally, research supervision was used on a frequent basis to address potential
biases that the researcher might have had when synthesizing the data.
Methodological critique
The methodological quality of the identified studies was assessed with Walsh and Downe’s
(2006) framework of quality appraisal (Appendix 1.4). The selection of this framework was
due to its focus on appraising qualitative studies that are included in meta-syntheses. Walsh
and Downe’s (2006) quality framework examines eight key domains in qualitative studies:
namely scope and purpose; design; sampling strategy; analysis; interpretation; reflexivity;
ethical dimensions; and relevance and transferability. A score of 0 was given for those
domains that were absent. The domains that were partially met were given a score of 1
whereas a score of 2 was given to domains which fully met the criteria. To ensure the
reliability of appraisals an independent rater, reviewed a subsample of studies. Although the
methodological quality was assessed, this was not intended to provide a basis to exclude
papers. Instead, studies were incorporated into the meta-synthesis in order of their total
quality rating. Scores were used to identify the methodologically strongest studies to guide
the initial steps of the meta-synthesis. The methodologically strongest studies were
thematically analysed first to generate an initial set of themes before analysing subsequent
studies. A priori, we decided not to report scores for the studies’ quality as an outcome of this
review, as it would conflict with the commitment to qualitative methods.
There was a 100% agreement between the lead researcher and the independent rater
on the domains that were judged to be absent. Variation between ratings was noted for
domains that were partially (score of 1) or fully met (score of 2) in the included studies.
8
Walsh and Downe (2006) noted one of the limitations of using a checklist approach is related
to the difficulty of distinguishing the methodological quality from the quality of the write up
which is likely to be affected by each journal’s word limit criteria. Therefore, it was decided
to comment on strength and weaknesses of each study rather than presenting a numerical
representation, reinforcing our apriori decision not to present scores as outcomes. These are
provided in Appendix 1.2 to ensure transparency in our conduct of this rating.
Data Synthesis
The data from the studies were synthesised drawing on Noblit and Hare’s (1988) method of
meta-ethnography. Meta-ethnography is a type of meta-synthesis that was chosen to
synthesise the qualitative data from the included studies due to its flexibility in synthesising
data from various qualitative methods (Ring, Ritchie, Mandara & Jepson, 2011). The first
stage of the synthesis involved reading each study to enable the researcher to immerse
themselves in the data. A list of themes based on participants’ and authors’ quotations (and
thematic analyses) was generated. Themes from the methodologically strongest studies were
initially compared to understand how they were related to each other. The final step involved
interpreting the themes that related to each other across the studies. Emerging coding
frameworks were discussed in research supervision to refine codes and relationships. A
comparison of matching codes to themes between the lead researcher and an independent
rater suggested a 92.5% agreement.
Results
The outcomes of the search strategy are displayed in Figure 1. A total of 11 papers were
included in the meta-synthesis. Table 1 shows a summary of each study. Some of the selected
studies involved only service users or staff participants, whereas others involved staff, carers
9
and service users. The studies included in the analysis also differed in the qualitative
methods they used to analyse their data.
Figure 1. PRISMA flow diagram
10
Table 1
Themes of the included studies that were used in data synthesis
Study
(year)
Country
Method of
Analysis
Participants Article themes related to the
implementation of CBTp
Dunn,
Morrison
& Bentall
(2002)
UK
Grounded Theory 10 service users
(four female)
Themes: (1) motivation (2) memory (3)
task difficulty (4) putting off (5) the
need for a rationale (6) the perceived
benefits of therapy (7) insight (8) the
effort required to complete assignments
and (9) the perceived relevance of the
assignments to the patients’ needs
Hazell,
Strauss,
Cavanagh
& Hayward
(2017)
UK
Thematic analysis 21 service users
124 mental health
clinicians
Themes: (1) Presenting problem, (2)
Practical Barriers (3) The therapist
Iredale,
Fornells-
Ambrojo,
& Jolley
(2016)
UK
Thematic analysis 10 service users (7
female) 12
Therapists (8
female).
Themes: (1) Access to psychological
interventions, (2) experience of
psychological interventions, (3)
Motivation to engage with
psychological therapy (4) Case
complexities
Landau &
Ruddle,
(2017)
UK
Thematic analysis 8 service users (4
male)
Themes: (1) Positioning of therapy, (2)
To improve is to change (3) therapeutic
alliance, (3) Frustrating findings
Li et al.,
(2017)
China
Systematic
Content and
Question Analysis
15 Service users (7
female) 15 carers
(12 female) 15
Psychiatrist (8
female).
Themes: (1) Culture and related issues,
(2) Importance of language and
communication, (3) Issues related to
system and resources, (4)
Understanding of illness and beliefs
about its cases and its management, (5)
Assessment, engagement and
adjustments to therapy
11
McGowan,
Lavender
& Garety,
(2005)
UK
Grounded theory
4 Clinical
psychologists
8 service users
Categories related to factors influencing
outcomes in CBTp:(1) Ability to engage
in clear and logical thinking, (2)
Continuity in Therapy, (3)
Remembering and Understanding
therapy, (4) Therapeutic alliance-shared
goal, (5) understanding, holding and
engaging with the therapist’s model.
Messari &
Hallam
(2003)
UK
Discourse
Analysis
5 service users (1
female).
Themes (1) CBT as a healing process,
(2) CBT as an educational process, (3)
CBT as a respectful relationship
between equals (4) CBT participation as
compliance with the powerful medical
establishment.
Naeem et
al., (2016)
Pakistan
Systematic
content and
Question analysis.
33 Service users
(15 female), 30
Carers (19 female)
29 Mental health
professionals (15
female).
Themes: (1) Culture and religion, (2)
Therapy issues, (3) Views about
schizophrenia, its causes and its
management (4) Awareness of illness
and pathways to care (5) Management
of illness
Newton,
Larkin,
Melhuish,
& Wykes
(2007)
UK
Interpretive
Phenomenological
Analysis
8 service users (5
female).
Theme: (1) An inductive account of
coping with auditory hallucinations.
Prytys,
Garety,
Jolley,
Onwumere,
& Craig
(2011)
UK
Thematic
Analysis
20 Care
coordinators (16
female)
Themes: (1) Understanding and beliefs
about psychosis, (2) Beliefs about
attitudes to clinical guidelines and
psychological therapies, (3) Views on
the role of care coordinator, (4) Factors
affecting implementation
Waller et
al., (2015)
UK
Thematic
Analysis
17 service users
7 mental health
staff
Themes: (1) Positive aspects of the
intervention (2) Challenging aspects of
the intervention, (3) Future
implementation into services, (4)
Difficulties encountered during therapy
(5) ideas for improvement
12
Methodological review of the studies
All of the eleven studies documented the rationale, scope, and aims. Concerning the design,
only three studies (Li et al., 2017; Messari & Hallam, 2003; Naaem et al., 2014) referred to
the epistemological underpinning of their selected qualitative method. Some papers (e.g.
Hazell, Strauss, Cavanagh, & Hayward, 2017; Prytys et al., 2011; Waller et al., 2015)
provided detailed justifications for the use of qualitative methodology and their chosen
method, without however mentioning the epistemology of their study.
All studies provided detailed inclusion criteria and discussed sufficiently their
sampling strategy. Regarding the analysis, all studies provided details of their chosen
approach, steps they have taken to analyses and the inter-rater reliability for the selected
themes. However, only three studies (Li et al., 2017; McGowan, Lavender, & Garety, 2005;
Naeem et al., 2016) returned a sample of their transcripts to participants for comments and
verification. In relation to the interpretation of findings, most of the studies discussed the
decision trail to reach their conclusion, and all utilised participants’ quotations to support
their conclusions. Two studies (Li et al., 2017; Naeem et al., 2016) used field notes to capture
the non-verbal communication of their participants during interviews.
Concerning researchers’ reflexivity, all but two studies (Dunn, Morrison, & Bentall,
2002; McGowan et al., 2005) have referred to researchers’ biases and the impact that this
could have on the interpretation of their findings. Hazell et al. (2017) quote: “the book is
authored by two of the authors of this paper. Consequently, it is possible that our findings
could be vulnerable to a positive research bias” (p. 13) provides a good example of
researchers acknowledging their parallel roles and the impact that this can have on data
analysis.
All but two studies (Dunn et al., 2002; McGowan et al., 2005) demonstrated a degree
of sensitivity to ethical issues by describing the process of obtaining consent from research
13
participants. Some papers even provided details of ethical approval (e.g. Hazell et al., 2017).
All papers reported the relevance of their findings to existing theories and knowledge.
The meta-synthesis started with the methodologically strongest studies (Hazell et al., 2017; Li
et al., 2017; Messari & Hallam, 2003; Naeem et al., 2016; Prytys et al., 2011; Waller et al.,
2015). Following this, the remaining studies were further analysed to search for new
emerging themes or data that would disconfirm our initial themes.
Meta-synthesis
Three overlapping themes, each with two subthemes, were identified. The themes
summarised the perspectives of stakeholders regarding the barriers of implementing CBTp
(see Appendix 1.3 for list of overarching themes). The ‘difficulties in seeking treatment’
theme consisted of the ‘motivation to engage’ and ‘practical difficulties’ subthemes. The
‘challenges of providing care’ theme consisted of the ‘professionals’ confidence and practical
challenges’. The ‘service design’ theme comprised of the ‘lack of resources’ and ‘conflicting
needs’ subthemes. Figure 2 demonstrates the interaction of the three themes which results in
difficulties in implementing CBTp in services. The language used to describe the themes
might need an adaptation overtime to improve the precision of the effects seen. For example,
the “motivation to engage” subtheme might reflect at times approach or avoidance variants.
14
Figure 2. An illustration of the interactive and overlapping nature of the themes related to the
implementation of CBTp.
Difficulties in seeking treatment
All but one study (Prytys et al., 2011) contributed to this theme. The participants expressed
their perspectives regarding the challenges that they faced to get access to CBTp. These
challenges consisted of two subthemes: ‘motivation to engage’ and ‘practical difficulties’
Motivation to engage
Several factors affected service users’ motivation to engage with CBTp. Studies conducted
outside the UK (e.g. Li et al., 2017; Naeem et al., 2016) reported the impact of culture and
religion on illness attributions, which have influenced the treatment preferences: “It usually
starts with seeking help from non-medical healers at the initial stages of the illness. Before
CBTp implementation
Difficulties in seeking treatment
Motivation to engage
Practical difficulties
Challenges of providing care
Professionals' confidence
Practical challenges
Service design
Lack of resources
Conflicting needs
15
coming to the psychiatric health facility almost everyone had seen a traditional/ faith healer”
(Author’s quote, Li et al., 2017, p. 5)
Furthermore, Newton et al. (2007) outlined that explanations that carers and service
users gave to psychotic experiences affected the perceived sense of control over their
symptoms, which in turn influenced their engagement with CBTp: “In contrast, the religious
beliefs in Mark’s family seem to have a negative impact on his coping with auditory
hallucinations.” (Author quote, p. 141). Li et al. (2017) study highlighted the impact of
stigma on help-seeking: “The stigma is a big problem; the patients are reluctant to come or
even refuse to see psychiatrists.” (Participant quote, p. 5).
Communication with mental health professionals and the ability to understand the
concepts of CBTp were influenced by the socio-economic background of service users and
carers and played a key role in their engagement:
The low socio-economic level of the patients and their family members is the biggest
barrier. Many patients and their family members have difficulty communicating with
the doctors, and they do not want to spend time and energy in family therapy or CBT.
(Participant quote, Li et al., 2017, p. 6).
Studies which explored service users’ perspectives (Hazell et al., 2017; Waller et al.,
2015) referred to individuals’ concerns regarding potentially increased distress or symptom
deterioration when engaging with CBTp: “If I’m focussing on something that is specifically
about hearing voices and how to help that situation, my voices will not like that” (Participant
quote, Hazell et al., 2017, p. 7). Cognitive difficulties such as attention and memory affected
the perceived gains of service users from therapy and thus their engagement with CBTp: “I
re-read the same thing so that could be a barrier to accessing the therapy” (Participant
16
quote, Hazell et al., 2017, p. 7). This also had an impact on service users’ compliance with
homework tasks: “Some people identified challenges with therapy. A common issue was
difficulty in completing homework” (Author quote, Landau & Ruddle, 2017, p. 38) and
treatment materials: “would have preferred a different format without that paperwork”
(Participant quote, Waller et al., 2015, p. 308,). The difficulty of engaging with treatment
materials potentially limited the perceived benefits of service users from CBTp as illustrated
by the following quote: “Umm, there wasn’t. I, I, I didn’t get any help from it” (Participant
quote, Messari & Hallam, 2003, p.176). This might have affected the preference that some
service users had for medication over CBTp: “They only want medicines. They want quick
cures. Some of them would say, how can you treat me by talking?” (Participant quote, Naeem
et al.,2016, p. 49).
Practical difficulties
Studies referred to the lack of awareness of service users and families about the evidence
base for CBTp and the ways that CBTp can help with their difficulties: “Only a few had
heard of psychotherapy. Other did not know what it means. Those who knew of
psychotherapy, mainly considered it to be counselling” (Authors quote, Li et al., 2017, p.7).
Moreover, the lack of specialist care provision in some areas meant that even when families
wanted to engage with CBTp they had to travel long distances to get access to it, which also
had a significant financial implication: “How can they come back for therapy if they are
coming from Dera Ghazi Khan (2–3 days travel distance)? (Participant quote, Naeem et al.,
2016, p. 49). Iredale, Fornells-Ambrojo and Jolley (2016) reported that psychotic symptoms,
such as suspiciousness and anxiety, about leaving home environment deterred service users
from accessing mental health services in the community: “getting the bus [is] an incredibly
stressful experience’’ (Participant quote, p. 207). The houseboundness of people with
17
psychosis was further increased by comorbid physical health difficulties: ‘‘[pain is] worse
when [I’m] moving around’’ (Participant quote, Iredale et al., 2016, p. 207).
Challenges in providing care
All but two studies contributed to this theme (Messari & Hallam 2002; Landau & Ruddle,
2017). This theme comprised of professionals’ challenges of delivering CBTp. Such
challenges were related to professionals’ confidence in delivering therapy and the practical
challenges that they faced in providing CBTp.
Professionals’ confidence
Participants referred to the limits of CBTp effectiveness in the long-term, which affected their
motivation to consider CBTp as a treatment option: “What I have seen is that people find it
quite hard to sustain” (Participant quote, Prytys et al., 2011, p. 54). Increased workload along
with experiences of limited benefits from CBTp impacted on professionals’ confidence in the
evidence base and clinical guidelines, as they perceived them as not being realistic:
the bodies that produce these guidelines and it can feel like, you know, something we
need to know about but do they really know what it is like down on the ground level
where we are struggling to just manage the vast number of people on the caseload
(Participant quote, Prytys et al., 2011, p. 54).
The severity of psychotic symptoms which was defined by limited insight, complexity,
and chronicity, appeared to have shaped professionals’ experiences when delivering CBTp:
“These complexities appeared to impact on the staff members’ confidence and the service
user’s engagement with the intervention” (Author quote, Waller et al., 2015, p.304).
18
Professionals’ confidence was further affected when the severity of symptoms was combined
with a perceived lack of motivation from service users’ side to engage with CBTp: “As they
did not perceive the tasks as relevant to solving their problems, they experienced low
motivation to undertake the tasks and an increased tendency to put them off.” (Author quote,
Dunn et al., 2002, p. 364). Such experiences led professionals to believe that receiving
specialist training was essential to be able to deliver CBTp: “Another important theme that
emerged was the importance of having specialist workers in the team to offer a psychological
intervention” (Author quote, Prytys et al., 2011, p. 55).
Practical challenges
Li et al. (2017) suggested that difficulties with attendance could increase the dropout rates
when offering CBTp: “Mental health professionals reported up to 80% drop-out from the
follow-up” (Author quote, p. 6). Additionally, difficulties in family relationships and
subsequent lack of support seemed to further hinder the implementation of CBTp: “Usually
we find a family member who can act as a co-therapist. But if we can’t do this then prognosis
is poor” (Participant quote, Naeem et al., 2016, p. 50). Mental health professionals referred to
the challenges of implementing CBTp protocols which were not adapted to the cultural,
educational and religious background of their clients: “It is important to involve elements of
religion and culture in therapy here. Then it becomes useful. If you don’t understand religion
and culture you can’t give therapy” (Participant quote, Naeem et al., 2016, p.48).
Additionally, cognitive difficulties that service users experienced, provoked feelings of
frustration to professionals, which were mediated by the perceived benefits that they have
from each session: “Simply forgetting something that was blatantly obvious in the previous
session. And it’s almost as if every session is new ground.” (Participant quote, McGowan et
al., 2005, p.521).
19
Hazell et al. (2017) reported that viewing psychosis solely as a medical illness
affected the priorities that services have in managing referrals, which then influenced the
support that professionals received in delivering CBTp: “I think there will be resistance from
practitioners who rely solely on the medical model.” (Participant quote, p. 11).
Service design
Seven studies contributed to this theme (Hazell et al., 2017; Iredale et al., 2016; Landau &
Ruddle, 2017; Li et al., 2017; Naeem et al., 2016; Prytys et al., 2011; Waller et al., 2015).
Participants in these studies referred to the service level barriers which consisted of the
following subthemes: ‘lack of resources’ and ‘conflicting needs’.
Lack of resources
Prytys et al. (2011) outlined that the combination of increased demand for mental health
services and lack of resources impacted on the pressure that professionals experienced in
daily clinical practice. This affected the priorities that professionals had when working with
people with psychosis: “we had this influx of, you know, a heavy caseload and the focus
became more on keeping them stable, sort of, we are saying by, just compliance with
medication and very little support” (Participant quote, p. 55). Additionally, the pressure to
assess more people within services limited the time that professionals had to attend
supervision for CBTp: “one-to-one social inclusion work you’re not used to group
supervision really, so I can see the value of it ...it’s just finding the time really ...it was
difficult” (Participant quote, Waller et al., 2015, p. 304).
Professionals also referred to the pressure that they felt to deliver good outcomes in
the least amount of time: “All staff are asked to do unrealistic amounts of work, and this
[guided self-help CBTv] may simply need too much time” (Participant quote, Hazell et al.,
20
2017, p. 11). Furthermore, Prytys et al. (2011) outlined the importance of having staff trained
in CBTp in order to facilitate referrals: “Five referred to the beneficial effects of having
specialist workers present in the team for easing referral for psychological therapies and
communication regarding clients” (p. 55). However, one of the consequences of limited
resources was the difficulties of having staff trained in CBTp: “CMHT workers in this study
frequently highlighted the lack of such provision” (Author quote, Prytys et al., 2011, p. 57).
Conflicting needs
Investing in CBTp was perceived as producing limited outcomes: “It seems to me that as
psychosis does not produce results or turnover suitable to corporate organisations it
[treatment provision] will remain the poor relation within services” (Participant quote,
Hazell et al., 2017, p.11). Hazell et al. (2017) outlined that CBTp was seen as a secondary
option for services that needed to meet certain treatment and financial targets. This led staff
to perceive that there were not adequately supported to deliver CBTp: “I am dependent on
managers who may be pressured to achieve targets and may not see interventions such as
these as essential” (Participant quote, p. 11). The long waiting lists for psychosis treatment in
services created a sense of hopelessness amongst professionals:
I am too frightened to tell them because they will want it then and there, so I will only
tell people who are very suitable. I’m not doing anything to increase awareness,
what’s the point? When they will be on the waiting list for over a year? (Participant
quote, Prytys et al., 2011, p. 56).
This was also reflected amongst service users: “People go round and round in
circles, discharged too early” (Participant quote, Landau & Ruddle, 2017, p. 38). Prytys et
21
al. (2011) reported the importance of clinical leadership in terms of providing clarity in
professionals’ roles in the implementation of CBTp: “I think there also would be role
confusion; you know, it would be very difficult slipping in and out of roles.” (Participant
quote, p. 55). Another aspect of difficulties with clinical leadership reported in Waller et al.
(2015) related to the confusion around referral criteria for CBTp and suitability for
psychological intervention:
This included discussion of how suitable service users would be identified and
differentiated from those who might be better suited to other interventions, including
a full course of CBT for psychosis. There were some contrasting views regarding who
might be most suitable for brief, structured work. (Author quote, p. 305).
Consequently, the lack of clarity concerning the referral suitability criteria deterred
professionals from referring people. Hazell et al. (2017) reported that the pessimism that
staff experienced regarding implementing CBTp was likely to affect the perceptions of the
organisation around psychosis treatment and lead to a vicious cycle: “While this attitude
remains, commissioners are unlikely to invest in CBTp” (Author quote, Hazell et al., 2017, p.
12). On the other hand, using the medical model to guide the treatment of psychosis was
perceived as something which assisted services in meeting their targets: “It appeared that
some felt an intervention like this conflicted with the priorities of services on two main fronts:
firstly, a conflict with the dominant treatment model, and secondly the need to meet targets”
(Author quote, Hazell et al., 2017, p. 11).
22
Composition of meta-synthesis
Most of the data from each study were used in the meta-ethnography and contributed to the
development of the themes in this study. Table 2 illustrates the contribution of each study to
the development of each theme in this review. The themes: ‘this is truly happening’, and ‘I
am ill’ (Messari & Hallam 2003) were not used in this review as they mainly referred to
service users’ attempts to make sense of their psychotic experiences. Additionally, the theme
‘a place to explore shared experiences’ (Newton et al., 2007) referred to the positive aspects
of a group therapy and thus was also not included in the current review.
23
Table 2
The contribution of each study to final themes
Studies
Themes
Difficulties seeking help Challenges providing care Service Design
Motivation
to engage
Practical
difficulties
Professionals’
confidence
Practical
challenges
Lack of
resources
Conflicting
needs
Dunn et al., 2002 X X X
Hazell et al., 2017 X X X X X X
Iredale, Fronells-
Ambrojo, & Jolley,
2016
X X X X X X
Landau, & Ruddle,
2017
X X X
Li et al., 2017 X X X X X X
McGowan et al.,
2005
X X X X
Messari & Hallam,
2003
X X
Naaem et al., 2014 X X X X X X
Newton et al., 2007 X X X
Prytys et al., 2011 X X X X
Waller et al., 2015 X X X X X X
24
Discussion
The aim of this meta-synthesis was to explore key stakeholders’ experiences and views in
relation to the routine implementation of CBTp. ‘Difficulties in seeking treatment’,
‘professionals’ challenges of delivering CBTp’ and ‘services design’ were the three
interlinked and overlapping themes which were constructed from the data during the
synthesis. Each theme consisted of two subthemes which mainly described the motivational
and practical challenges that professionals, service users and organisations faced in
implementing CBTp.
Consistent, with previous systematic reviews (e.g. Berry & Haddock, 2008; Ince et al.,
2016) our findings suggest that barriers to CBTp implementation are related to recipients
(service users, carers) as well as providers (organisation, staff) of CBTp. Given the
exploratory nature of meta-synthesis (Noblit & Hare, 1988), our findings attempt to formulate
the interplay between various barriers to implementation of CBTp, rather than simply provide
a descriptive summary of the literature. Several factors affected service users’ motivation and
ability to engage with CBTp. These factors, in turn, had an impact on professionals’
confidence and capacity to deliver CBTp. The difficulties with engagement and delivery of
CBTp influenced the organisational priorities which were not in favour of investing in CBTp,
maintaining thus difficulties in implementation.
Similar to a recent systematic review which explored pathways to care in psychosis
(Gronholm, Thornicroft, Laurens, & Evans-Lacko, 2017) the results indicated that stigma and
perceived discrimination influence help-seeking behaviours and often deter service users
from engaging with CBTp. However, evidence has shown that adapting CBTp to specific
cultures can reduce feelings of stigma, improve symptom reduction and attendance (Rathod
et al., 2013). Another finding was that the travelling distance, in combination with
difficulties leaving the house due to comorbid mental and physical health problems, can
25
affect the implementation of CBTp. This finding potentially highlights the importance of
increasing services’ flexibility, in terms of time and location of appointments. Given the
importance of homework tasks in CBTp (Morrison, 2017), our findings suggest that these
should be adapted to match the specific needs of service users and to ensure a user-friendly
experience of CBTp.
The lack of clinical leadership translated into confusion about professionals’ roles in
the implementation of CBTp and resulted in unclear referral pathways. Additionally, the lack
of protected time was frequently mentioned in our findings as a crucial barrier to CBTp
implementation following training. This finding is supported by a recent pilot study which
reported consistent clinical leadership to be an important predictor of successful CBTp
implementation during the pilot period (Gray, Stevens, Motton, & Meddings, 2017).
Methodological strengths and weaknesses
To our knowledge, this is the first meta-synthesis, which incorporates professionals’, carers’
and service users’ views on the implementation of CBTp. This meta-synthesis involved
studies conducted in and outside of the UK and aimed to explore barriers to implementation
in various mental health systems and cultures. Additionally, although our aim was to
synthesise qualitative data, we did not exclude studies with mixed-methods design to increase
the inclusivity of our search strategy.
The aim of the meta-synthesis was to explore both facilitators and barriers to CBTp
implementation, however, most of the studies that met our inclusion criteria focused on
barriers to implementation. Additionally, the exclusion of grey literature and government
reports might have limited the scope of our findings. Similarly, we included only studies
conducted from 2002 to 2018. However, in order to increase the sensitivity and the scope of
26
our search strategy we checked reference lists and conducted citation searches of the included
studies.
Given the interpretive nature of our meta-ethnography (Noblit & Hare, 1988), our
findings might have been affected by researchers’ biases. To address this, all the sources of
potential bias were discussed prior to the search of the studies. Additionally, during data
synthesis a reflective log was kept by the researcher and used in supervision to discuss
potential sources of bias in interpretation. Quality appraisal of the included studies was used
to analyse in a hierarchical order the studies, starting with the methodologically strongest
ones. To minimise potential bias, an independent rater was used for the quality appraisal as
well as to compare emerging themes across the studies.
Implications
One of the benefits of qualitative meta-synthesis is that by comparing and identifying
common themes across qualitative studies, it offers a deeper understanding and
interpretations of the literature (Sandelowski & Barroso, 2007). The results of this synthesis
produced a model which aims to portray an interaction between barriers in seeking,
delivering and investing in CBTp. This model suggests that the barriers encountered on
service user/carer level (e.g. houseboundness, illness attributions, cognitive difficulties,
severity of symptoms) can interact with professional level factors by reducing the confidence
that professionals have to deliver CBTp and thus increase their requirements for training and
supervision. These factors in turn interact with the organisation level variants as health boards
are required to increase investment (e.g. supervision, protected time, defined roles) and adapt
their approach (e.g. flexibility in appointment times, outreach support) while trying to meet
treatment targets and financial targets.
27
We consider that future quantitative studies could explore the utility and validity
of this model when exploring stakeholders’ experiences of implementing CBTp. Our findings
also suggested that families’ and carers’ perceptions and support affected service users’
engagement with CBTp. However, only two of the included studies explored family and
carers’ views (Li et al., 2017, Naeem et al., 2016). This highlights the importance of
involving this stakeholder group in the future CBTp implementation research.
The results of this meta-synthesis could be used by service managers and clinicians
to predict and address potential difficulties in implementation when developing training
agendas for staff. Another implication of our findings is that they offer a systemic
conceptualisation of successful implementation of CBTp, meaning that the responsibility in
implementing CBTp relies on the collaboration of all key stakeholders. This highlights the
importance of involving service users and carers in service design and delivery.
Conclusion
To our knowledge, this is the first meta-synthesis of implementation of CBTp in services.
The synthesis of qualitative studies produced a cyclical model of barriers to CBTp
implementation. Barriers to help-seeking (e.g. motivation, symptom severity, illness
attribution, cognitive difficulties, attendance) pose specific challenges to professionals who
offer CBTp (e.g. confidence, requirements for supervision, training, protected time). These,
in turn influence the organisational priorities (e.g. medical model, ethos) when trying to meet
targets with limited resources. Future studies can use the model of this synthesis to formulate
and address potential barriers to CBTp implementation in their localities.
28
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Chapter two: Major Research Project
Exploring the implementation of Cognitive Behavioural Therapy for psychosis
(CBTp) using the Normalisation Process Theory (NPT) framework
Nikos Xanidis*
Submitted in partial fulfilment for the Doctorate of Clinical Psychology
(DClinpsy)
*Address for Correspondence: Academic Unit of Mental Health and Wellbeing, University of
Glasgow, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow, G12 0XY. E-mail:
Prepared in accordance with submission requirements for Psychology and Psychotherapy:
Theory, Research and Practice (see Appendix 1.1)
Word count including references: 7011
34
Plain English Summary
Title: Exploring the implementation of Cognitive Behaviour Therapy for psychosis, using the
Normalisation Process Theory framework.
Background: Cognitive Behavioural Therapy for psychosis (CBTp) is an individually
tailored talking therapy which aims to help people with psychosis develop helpful coping
strategies for specific psychotic symptoms (e.g. hearing distressing voices). National clinical
guidelines recommend CBTp to be offered to any person experiencing psychosis. However,
only a small minority of service users (5-10 %) have access to CBTp. Normalisation Process
Theory (NPT) attempts to explain the processes for a successful implementation of
interventions in routine clinical practice.
Aims/ Questions: This study used NPT to explore the experiences and views of NHS mental
health staff regarding the implementation of CBTp. Specifically, (a) how do mental health
professionals working with people experiencing psychosis make sense of CBTp
implementation and (b) can professionals’ perspectives be understood within the NPT
framework?
Methods: A total of 14 mental health professionals from different professional backgrounds
attended either a focus group or an individual interview and provided their experiences of
implementation of CBTp. Interviews were audio recorded and transcribed verbatim.
Transcriptions were analysed using thematic analysis. Subsequently, the initial themes were
mapped onto the constructs of NPT.
Main Findings: Themes consisted of the perceived benefits of CBTp, the challenges of
implementing CBTp routinely, and ways to address difficulties in implementation. All but
two subthemes mapped onto the NPT framework. NPT analysis of themes suggested that
professionals had difficulties in agreeing about the purpose and benefits of CBTp. This was
translated into the service’s lack of confidence in investing in CBTp.
35
Conclusion: Professionals were willing to support the wider implementation of CBTp
however, difficulties in making sense of CBTp among professionals and a lack of collective
action from services hindered the implementation. The findings suggested that strong clinical
leadership could increase professionals’ awareness and service investment in CBTp.
36
Abstract
Objective: Evidence suggests that only a minority of service users experiencing psychosis
have access to Cognitive Behavioural Therapy for psychosis (CBTp). Normalisation Process
Theory (NPT) is a theoretical framework which focuses on processes by which interventions
are implemented and normalised in clinical practice. This study explored the views and
experiences of mental health professionals regarding the implementation of CBTp. Barriers
and facilitators to implementation were explored using the NPT framework.
Design: A qualitative methodology was adopted involving semi-structured focus groups and
individual interviews.
Methods: A total of 14 members of staff working in the community and crisis mental health
teams were recruited. Thematic analysis was used to generate initial themes. The Framework
approach was utilised to map initial themes to the NPT framework.
Results: Inductive coding generated five overarching themes consisting of 15 individual
subthemes which captured the perceived barriers to engagement; contextual barriers to
implementation; optimisation of implementation; positive attitudes towards implementation;
and expectations of implementing CBTp. All but two subthemes mapped on to the NPT
framework. The deductive analysis suggested that difficulties in making sense of CBTp
among professionals were reflected as service level barriers which impeded wider
implementation.
Conclusion: The results of this study suggested a mixture of barriers and facilitators to
CBTp implementation. Interpreting our findings within an NPT framework indicates the
importance of strong clinical leadership to address difficulties in sense-making and service
investment in CBTp.
37
Introduction
Cognitive Behavioural Therapy for psychosis (CBTp) is an individually tailored talking
therapy which aims to increase an individual’s coping with specific psychotic experiences
(e.g. hearing distressing voices) by modifying associated thoughts, physical sensations,
behaviours and emotions (Morrison, 2017). A recent Delphi consensus study reported that the
essential aspects of CBTp involve collaboration, formulation, normalisation and change
strategies (Morrison & Barratt, 2010). These ingredients and processes were perceived by
service users to improve engagement and reduce stigma, as reported in a recent synthesis of
qualitative studies (Berry & Hayward, 2011).
Evidence from randomised controlled trials (RCTs) indicates that CBTp results in a
reduction of positive symptoms (Wykes, Steel, Everitt, & Tarrier, 2008) and comorbid
difficulties (Turner, van der Gaag, Karyotaki, & Cuipers, 2014). Additional evidence
suggested that CBTp may also prevent the onset of psychosis in people who were at risk of
developing psychosis (Hutton & Taylor, 2014). National Institute of Clinical Excellence
(NICE, 2014) guidelines in England and Wales and the Scottish Intercollegiate Guidelines
Network guidelines (SIGN (131), 2013) recommended that CBTp should be offered to all
individuals who either experience or are at risk of experiencing psychosis over the course of
at least 16 sessions.
Although national guidelines have increased professionals’ awareness (Fadden, 2006)
regarding the benefits of CBTp this has not been followed by successful implementation of
CBTp into routine care (Rowlands, 2004). A recent national audit in the UK estimates that
only one in ten people with psychosis have access to psychological interventions
(Schizophrenia Commission, 2012). Ince, Haddock and Tai (2016) reported that the rates of
implementation of CBTp varied significantly across studies and this was attributed to
differences in the methodological quality of the studies. Berry and Haddock (2008) suggest
38
that barriers can be classified into three main categories, which involve service recipients’
factors such as poor engagement and family support. The second set of barriers related to
professionals’ negative perceptions of CBTp and lack of competence in delivering CBTp
(Prytys, Garety, Jolley, Onwumere, & Craig, 2011). The third cluster of barriers was
associated with organisational factors reflecting difficulties with access to training,
supervision and having protected time to implement CBTp (Ince et al., 2016). Arguably, the
small effect sizes of CBTp that were reported in a recent meta-analysis (Jauhar et al., 2014)
have also provoked a debate among clinicians about its perceived efficacy (McKenna &
Kingdon, 2014), which may have affected the consensus regarding the prioritisation of
resources.
Studies which investigated facilitators to CBTp implementation reported that high
intensity training improved the competency of the staff which resulted in increased
implementation. However, this depended on whether the staff had protected time to
implement CBTp following training (Jolley et al., 2012). Similarly, Gray, Stevens, Motton,
and Meddings (2017) highlighted the benefits of the availability of trained staff to participate
in team meetings to increase professionals’ awareness of CBTp.
The longstanding difficulties with the implementation of physical and mental health
treatments in routine clinical practice have led to the development of theoretical models
which aim to understand and aid the process of implementation. Normalisation Process
Theory (NPT; May et al., 2009) is one of the theoretical frameworks that focus on the
implementation of interventions, their embedding in routine practice and the processes by
which interventions are sustained or normalised. NPT consists of four components which
define distinctive processes that have been found to predict successful implementation. The
first component, Coherence refers to the extent to which stakeholders involved in
implementation have a sense of clear and common purpose of the intervention. Cognitive
39
Participation refers to the degree to which stakeholders perceive the potential benefits of the
intervention and the willingness to support the implementation. Collective Action relates to
the service level pragmatics involved in successful implementation. The fourth component,
Reflexive Monitoring refers to an agreed plan of how the implementation would be evaluated.
NPT predicts that implementation processes need to satisfy these four components to become
normalised in routine practice. Additionally, NPT suggests that these components are linked
with each other and thus changes in one part can affect the others.
Previous qualitative studies have used NPT framework to explore and formulate the
barriers to implementation of evidenced-based psychological interventions for depression
(Gunn et al., 2010) and bipolar disorder (Moriss, 2008). These studies suggested that the use
of NPT allowed them to assess, formulate and develop an intervention plan based on the
components of NPT to facilitate the implementation (McEvoy et al., 2014). Recently, Hazell,
Strauss, Hayward and Cavanagh (2017a) explored the views of mental health clinicians on
brief CBTp intervention using an NPT based questionnaire. Exploratory factor analysis of
the responses found support for all but one (collective action) construct of the NPT. Although
Michie and colleagues (2007) applied a theoretical framework to interpret barriers to
implementation of national guidelines for psychosis, this was focused on family interventions
and not CBTp. Additionally, previous studies exploring CBTp implementation have used
only one professional group (care co-ordinators; Prytys et al., 2011) rather than a mixture of
diverse professional backgrounds. This may have limited the understanding of the interaction
between experiences and perspectives of stakeholders, which subsequently restricted the
production of an intervention plan based on the theoretical model used, to overcome such
barriers.
40
Aims
The first aim of this study was to explore the experiences and perspectives of mental health
professionals concerning the implementation of CBTp in NHS Ayrshire & Arran (A&A). A
second aim was to apply the NPT framework to interpret potential barriers and facilitators to
implementation.
Research questions
1. How do mental health professionals working with people experiencing psychosis
make sense of CBTp implementation?
2. Can professionals’ perspectives be understood within the NPT framework?
Methods
Design
This study adopted a qualitative design to explore individuals’ experience as a phenomenon,
within the context and social reality of participants (Holloway, 1997). Focus groups with
participants from the same professional background and semi-structured individual
interviews were employed. The interview topic guide (Appendix 2.8) was developed to
reflect the research aim and questions. Additionally, the NPT framework was used to
prompt, guide and structure the questions of the topic guide and permit participants to reflect
on the NPT constructs. The epistemological positions behind this study followed the critical
realist and post-positivist paradigms, suggesting that the experience of participants and the
researcher is influenced by the social, structural and political context in which the study is
conducted (Danermark, Ekström, Jakobsen, & Karlsson, 2002).
41
Ethical considerations
Data were anonymised and stored in a password protected computer in line with University
of Glasgow guidelines on confidential data. The Research Proposal (Appendix 2.1) and
proposal amendments (Appendix 2.2) for this study were approved by the local Research and
Development Department and ethical approval was granted by the University of Glasgow
College of Medical, Veterinary and Life Sciences (Appendix 2.3 -2.5).
Procedure
Study adverts and introductory information (Appendix 2.6) were provided to the Community
Mental Health Teams (CMHTs) and Crisis Team (CT) leaders to circulate to their team
members. The lead researcher attended the team meetings to introduce the study and explore
interest. After obtaining verbal consent from participants, participant information sheets were
provided (Appendix 2.7). Prior to the interviews, the researcher explained issues of
confidentiality, anonymity, and the voluntary nature of participation and participants
provided written informed consent (Appendix 2.10). All interviews were conducted by the
lead researcher and took place in NHS A&A settings. Field notes were recorded after each
interview.
Participants
The experiences and views of several staff groups were sought as NPT assumes that everyone
has a role in successful implementation. The sample consisted of 14 participants, ten of
whom were female. Eligible participants have worked with individuals who have experienced
psychosis in NHS A&A CMHTs or CTs across the three geographical regions in A&A (East,
South, North). The average number of years of clinical experience of participants was 17.2
years. Participants consisted of mental health nurses (n =5) consultant psychiatrists (n = 2),
42
clinical/counselling psychologists (n = 2), CBT therapists (n =2), an occupational therapist (n
=1), a team leader (n =1) and a senior adult mental health manager (n =1). Two focus groups
(a nursing staff and a psychology focus group) and six individual interviews were completed.
The interviews lasted between 29 to 65 minutes.
Data Analyses
The first stage of analysis involved inductive thematic analysis (Braun & Clarke, 2006) as
our aim was to capture common patterns of experiences of CBTp implementation across a
variety of staff groups and to avoid forcing themes to the predetermined constructs of the
NPT. This helped us to identify deviant or new themes that might not be adequately captured
in the deductive framework. Previous qualitative studies in NPT research have successfully
used this approach to analyse data (MacFarlane & O’Reilly de Brun, 2012)
The inductive stage of analysis was conducted in line with Braun & Clarke’s (2006)
six stages of thematic analysis. Interviews were audio-recorded and transcribed verbatim.
The lead researcher initially immersed themselves in the data by reading the transcribed
interviews and noting down how participants made sense of their experiences. Complete
coding by analysing all the meaning units related to the research questions and aims was used
(Appendix 2.11). As the coding progressed, codes describing common experiences were
translated into themes. Once themes from each interview were identified, a list of overall
themes common across the dataset was developed. This phase involved discussing the themes
with an independent researcher and reaching a consensus regarding the definition and the
composition of each overarching theme by adding and subtracting the subthemes. The final
phase of inductive analysis involved selecting participants’ quotes to illustrate the identified
themes.
43
The deductive coding was completed using a framework analysis approach (Ritchie &
Spencer, 1994). This involved developing a list of all the subthemes that led to the
composition of the overarching themes. Following this, the lead researcher and an
independent researcher attempted to map these themes to the four constructs of the NPT.
Reflexivity
The lead researcher is a trainee clinical psychologist who has worked in a CMHT in NHS
A&A and in the past has used CBT with people experiencing psychosis. This provided the
researcher with an insight into barriers and facilitators to CBTp implementation.
Additionally, the lead researcher completed a systematic review of the literature concerning
the implementation of CBTp, which might have influenced their interpretation when
generating codes and themes. Potential sources of bias to data interpretation were discussed
in research supervision before the data collection and an independent researcher was involved
in data synthesis to minimise the risk of bias. A reflective log was kept during the data
collection process to reflect on sources of bias during interviews with participants.
Results
Inductive thematic analysis of participants’ experiences of CBTp implementation resulted in
five overarching themes (Appendix 2.9). Table 1 illustrates the subthemes that contributed to
the development of each of the overarching theme. Participants’ quotations which illustrate
each of the themes are presented in italics. 1
1 In quotations, material that has been omitted is indicated by ellipsis points (...). Words inserted for clarity are
represented by square brackets [ ]. Professional background, transcript page and line number are provided for
each quotation
44
Table 1
Overarching themes and subthemes of thematic analysis
Overarching themes Subthemes
Perceived barriers to engagement Symptom severity
Lack of attendance
Social environment
Contextual barriers to implementation Lack of resources
Lack of staff awareness of CBTp
Difficulties with referral pathways
The dominance of the medical model
Outcome driven services
Optimisation of the implementation Increasing professionals’ awareness
Supporting clinical leadership
Improving professionals’ communication
Positive attitudes to implementation Perceived benefits to service users
Perceived benefits to the professionals’
Expectations of implementing CBTp Objective outcomes
Subjective outcomes
Perceived barriers to engagement
Symptom severity
Participants referred to their experiences of attempting to implement CBTp. Applying a
structured treatment to address psychotic experiences which were chronic in nature meant
that recovery was difficult to achieve: “…you just know there’s these particular really fixed
beliefs that have been there for years and years and really there’s probably limitations in
what we can really do” (Nursing staff, p.5,105-108). Apart from chronicity, professionals
also referred to the severity of psychotic symptoms, such as lack of insight, that further
hindered the implementation of CBTp: “Sometimes is hard, but it’s a battle, is a long battle,
because it’s whether they’re accepting it’s their acceptance of their illness as well…”
(Nursing staff, p.5, 100). Difficulties managing any potential increase in distress of service
users when using CBTp further complicated the implementation: “…the last man that I dealt
45
with we did decide to put a hold to it, because he had reached a point where his tolerance of
the distress was as much as he could take” (Occupational Therapist, p.16, 352-354).
Lack of attendance
Service users’ motivation to accept the offered sessions affected professionals’ capacity to
deliver CBTp. For service users who initially engaged with CBTp the difficulty was the lack
of consistency in attendance rates and their ability to prevent possible drop outs: “Well
someone with psychosis tends to be less inclined to be seen and that’s the worry is that
they’re going under the radar because to have the time to pursue these patients is really
difficult” (Consultant Psychiatrist, p.21, 512-514).
Social environment
Professionals reported that social deprivation can determine service users’ preferences
regarding treatment: “…don’t really either see or feel motivated to engage in work that would
require some effort. That’s not true for everyone but perhaps is a little bit more true in a
deprived area” (Consultant Psychiatrist, p.4, 86-88). Family support in the recovery journey
of service users was a crucial element in the successful implementation of CBTp: “and the
family support as well, I think people who tend to do better, tend to be people who got stable
family and that support there as well” (Nursing staff, p.14, 311-313). Furthermore, attitudes
of peer groups affected service users’ lifestyle choices which impacted on their engagement
with services:
…but a bit like I was saying some of them are quite kind of chaotic life style, so they
come in they get a bit better but the go back out and it’s just kind of cycle with them
so, again to get them to engage it’s a bit trickier (Nursing staff, p.14, 269-271).
46
Contextual barriers to implementation
Lack of resources
An increase in workload was perceived as an indication of reduced resources. This induced a
feeling of pressure which affected professionals’ perceptions regarding the service’s priorities
when working with people with psychosis: “…I would get ripped over the course of not
doing their depo but nothing would happen to my registration if I didn’t offer that particular
intervention that we know can be as helpful as well” (Nursing staff, p.26, 582-585). A lack of
service investment in CBTp not only translated into a reduction in training opportunities but
also a lack of provision for supervision and protected time for staff that were already trained:
“…lots of people been training and they never use it because they weren’t supervised, there’s
no formal mechanism for them to have the confidence to try it” (Consultant Psychiatrist, p.27,
664-666). Limited protected time impacted on professionals’ confidence when applying
CBTp training into clinical practice, thus maintaining the difficulties with implementation:
“…I’ve got some skills in it, but I don’t always feel as confident in using them” (Nursing
staff, p.3, 63).
Lack of staff awareness of CBTp
Some participants described difficulties in understanding CBTp processes and how they
differentiate from a traditional CBT approach: “I am not entirely sure what is about to be
honest, other than I know what CBT is, and I know what psychosis is” (Senior manager, p.11,
251). This limited staff awareness of the potential benefits of CBTp: “I have only been in the
team for a year, I don’t know how effective CBT is with psychosis cause is not something I’ve
been involved in” (Nursing staff, p.26, 601). A lack of clarity around CBTp reinforced
professionals’ reluctance to refer people with psychosis, as illustrated by the following quote:
47
“it’s no an intervention that springs to mind when a patient comes up and they’re discussed”
(Nursing staff, p.25, 570).
Difficulties with referral pathways
Increasing demands for other mental health presentations had an impact on referrers’ attitudes
towards prioritising other patient groups that also needed psychological interventions: “…I
think because our services are so overwhelmed with emotional dysregulation, these are the
patients that are causing the problems and they are the ones that we tend to refer on”
(Consultant Psychiatrist, 11.257-259). Various factors such as demand, service targets and
resources shaped the referral suitability criteria for psychological interventions for psychosis:
…when you get small resource people wanted to be targeted to the people that are
most likely to benefit and that’s understandable but our patient population like
everywhere it’s not like that, you know they are not very many patients who will fulfil
all these criteria (Consultant Psychiatrist, p.24, 577-581).
Feelings of frustrations and hopelessness emerged when referrals for psychological
intervention for psychosis were not successful: “…they were not considered suitable and I
suppose I felt just a whole mixture of negative emotions about that” (Consultant Psychiatrist,
p.18, 432). This deterred professionals from continuing to refer other people from their
caseload: “The problem is like they’re saying we probably wouldn’t refer cause you know
they wouldn’t be accepted” (Nursing staff, p.27, 622). As a result, some professionals
reported a gradual decline in referrals for CBTp over the years: “…but the referrals are still
aren’t made, although I am not sure maybe there just not, maybe just these referrals aren’t to
made to team at all” (CBT therapist, p.13, 283). Additionally, actively seeking referrals for
48
psychosis was a challenging decision as participants reported the importance of meeting
service targets:
…we’re trying to meet the HEAT target, so we would never be going out to create
demand; I think that’s something we would never do but what we’re saying is that the
demand that’s coming to us is the demand that we’re meeting. (Clinical/Counselling
Psychologist, p.20, 467-469)
The dominance of the medical model
Participants reported the difficulties of challenging the perceptions of other professionals’
regarding the available treatment options in psychosis:
So I suppose it’s more to trying to help people not to just focus on the medical model
cause I think quite often in crisis especially that initial kind of referral period and the
initial appointment they referred; I think quite often we can; we’ll look to medication
for helping the person to. (Team Leader, p.5, 122-125).
Increase in workload, combined with time restraints reinforced the medical model of
psychosis as professionals tended to revert to practices they were more confident in: “Again it
comes downs to simply when people are under pressure or busy emmm..they will just stick
with what they usually do rather than implementing change”(Occupational Therapist,
p.11,240-242).
Outcome driven services
Limited resources combined with pressure to meet targets meant that professionals had to
make decisions about what needed to be prioritised in terms of service investment: “…but the
49
reality is that when you then introduce something else, another bit of the service has to be,
has to go if there is not an additional investment” (Consultant Psychiatrist, p.18, 430-432).
This meant that resources were allocated to interventions with the best evidence base for the
least required amount of sessions: “I think there has been a shift in emphasis towards well
good evidence, we can help people whose illnesses are shorter duration” (Consultant
Psychiatrist, p.10, 235). The need to achieve outcomes meant that CBTp was offered only to
service users with the best chances of benefiting from it: “But what we’ve seen is perhaps a
move certainly in psychology and perhaps even from other colleagues away from a process
model to an outcome model…” (Consultant Psychiatrist, p.4, 100).
Optimisation of the intervention
Increasing professionals’ awareness
Increasing competence in CBTp assessment was perceived as something that would help
participants decide the suitability for the intervention: “and if we get more information how
to assess people properly if they’re suitable for CBT with psychosis, you know” (Nursing
staff, p.32, 737). Some participants referred to the benefits of integrating awareness of CBTp
at the pre-qualification training: “So psychiatrist should by through their exams and by the
end of the training be very clear that they can recognise patients and scenarios in which a
CBT approach would be helpful…” (Consultant Psychiatrist, p. 23,533-535).
Supporting clinical leadership
Participants referred to the importance of having professionals with specialised training to
promote CBTp: “I don’t know it made people, it made everybody in the team think about it,
be enthusiastic about it” (Nursing staff, p.12, 272). Personal attributes such as enthusiasm
and actively seeking referrals for psychological intervention were also perceived as
50
facilitators to CBTp: “…I think you need a role or somebody in the position that is driving
that forward, somebody with enthusiasm for for intervention, for the principles” (Team
Leader, p.24, 574). To ensure the continuity of the implementation, it was important that
service structures supported clinical leadership by having a professional role in the
assessment and overview of the implementation: “so you need them to have erm kinda not to
sit in the side or the periphery of the line management structure to be involved in that and be
involved in a kinda central level” (Team Leader, p. 25,592-593). Another aspect of clinical
leadership that could facilitate the implementation was the development of referral protocols
adapted for CBTp: “…but I suppose maybe kind of the education and and how, how, good
they need to be how stable, how well would you need to have them before you can ever
consider” (Nursing staff, p.28, 628).
Improving communication
Improving communication in teams was an important facilitator to the implementation of
CBTp. Increasing inter-professional dialogues could increase trust and help professionals
understand different views and approaches:
I think, the more we have conversations with each other the more we’ve got good
relationships the more we understand what we should do the better can be for patients
and I think it doesn’t take much to start affect relationships (Consultant Psychiatrist,
p.23, 567-569).
Establishing effective inter-professional relationships could further facilitate
collaboration and consistency during the transition of service users from other services: “…if
you were lucky enough you would be passing over to someone that’s done the PSI training or
51
CBT training then that was great that was brilliant” (Team Leader, p.21,492-494). Another
aspect of communication and consistency was reflected in having clarity in professional
roles: “I think the psychology department think the CPNs are doing that but I don’t think the
CPNs know what that is or two feel confident in doing these things, so we’ve got this real
gap” (Consultant Psychiatrist, p.9, 210-212).
Positive attitudes to implementation
Perceived benefits to service users
Aspects of CBTp such as formulation were viewed as having a crucial role in engaging
service users: “So I do think that building a therapeutic rapport and the formulation is useful
parts of that approach which is definitely helpful…” (Clinical/Counselling Psychologist,
p.10, 220). CBTp was perceived as an approach that empowers recipients and increases the
sense of shared responsibility between the therapist and the client: “It is about people feeling
empowered to manage their own health, I think CBT allows that self-management and emm It
gives people quite concrete strategies” (Occupational Therapist, p.7,140-142).
Perceived benefits of CBTp to professionals
The benefits of CBTp were not limited only to recipients, but they also expanded to team
functioning. The structured approach of CBTp, as well as, the simple language encouraged
staff to use it in their clinical practice: “I think for me when I try to explain CBT and the
kinda I try to explain to the individual I think I feel that most people get the principles of
it…” (Team Leader, p.11, 262-263). Formulation was one of the processes of CBTp that was
perceived as valuable in increasing interprofessional understanding when working with
service users: “even if they’re just not ready or they don’t want to engage in treatment, but I
52
think a formulation, is really, really valuable in terms of informing all parts of care not just
the psychological treatment” (Consultant Psychiatrist, p.6, 139-141).
Expectations around the efficacy of CBTp
Objective outcomes
Participants referred to their expectations as sources of engagement and motivation in
delivering CBTp to service users. In order to evaluate these expectations, it was essential to
document outcomes of CBTp: “For example it’s not something that I see reported on so I am
not aware or getting stats on this number of interventions that we’ve delivered…” (Senior
Manager, p.12, 293). Indicators that CBTp was achieving its purpose involved a reduction in
psychosis symptoms, relapse and readmission rates: “From my service perspective you’re
looking at potentially less referrals to crisis team or less admissions for individuals
experiencing psychosis, less kinda erm maybe as well less medication…” (Team Leader,
p.26, 628-630).
Subjective outcomes
Using quality of life measures was considered an important aspect of CBTp effectiveness:
“but actually how about how do we look at it a bit closer and say well what’s that person’s
quality of life like in between the relapse” (Nursing staff, p.35, 812-813). Receiving feedback
from the wider network of service users was another way to measure aspects of functioning
following a CBTp course: “and the referrers and carers and that type of thing so you’ve got
feedback from outside people, the person itself and outcome measures” (CBT therapist, p. 25,
579-581). For some participants, subjective measures of success were perceived as stronger
reinforcers for continuing to use CBTp: “We can look at studies we hear all the evidence but
53
ultimately is once you start referring and you see people benefiting or engaging better”
(Consultant Psychiatrist, p.23, 555-557).
Framework Analysis
Thirteen out of the 15 subthemes were mapped to the four constructs of the NPT. Given that
NPT suggests that these constructs are linked with each other, a continuous cycle
representation of deductive coding was selected (see Figure 1). The construct of coherence
consisted of themes related to professionals’ views of CBTp. Cognitive participation
comprised of themes related to professionals’ willingness to support the implementation of
CBTp. The construct of collective action was mapped to the views that professionals had
about organisation level structures that were related to the feasibility of the implementation.
Professionals’ expectations of implementing CBTp were mapped to the reflexive monitoring
construct. The two themes which emerged from the inductive analysis and did not match the
NPT framework were: i) lack of attendance and ii) social environment. The inter-rater
reliability of mapping themes to NPT constructs was 86%.
54
Figure 1. Deductive coding of subthemes using the NPT framework
Discussion
The first aim of this study was to explore the experiences and views of mental health
professionals regarding the implementation of CBTp. Five overarching themes consisting of
15 subthemes captured a mixture of barriers and facilitators to CBTp implementation.
Overall, participants referred to the lack of provision of CBTp in their teams which confirms
reports from a recent systematic review regarding the low rates of CBTp implementation
(Ince et al., 2016). Similar to previous studies (Hazell, Strauss, Cavanagh, & Hayward,
2017b; Prytys et al., 2011) our findings indicate the difficulties that clinicians face when
implementing CBTp, which include the severity of symptoms and reported lack of insight of
people with psychosis. In addition, challenges with consistent attendance increased the
pessimistic attitudes of professionals regarding the feasibility of recovery and reinforced the
Coherence
Lack of staff awareness of CBTp
Symptoms' severity
The dominance of the medical model
Perceived benefits to service users
Perceived benefits to professionals
Cognitive participation
Increasing professionals' awareness
Improving communication
Collective action
Lack of resources
Difficulties with referral pathways
Supporting clinical leadership
Outcome driven services
Reflexive monitoring
Objective outcomes
Subjective outcomes
55
lack of implementation. In line with a previous study (Kingdon & Kirschen, 2006) this
finding indicates that certain clinical groups might not be offered access to psychological
therapies due to a disbelief that they would benefit from them.
Another perceived barrier to engagement which has been reported in previous studies
(Naeem et al., 2016) was related to social factors such as peer and family support. In line
with Braehler and Harper (2008), our findings suggest that psychological needs are often
overlooked or perceived as secondary when professionals are faced with high caseload and a
pressure to achieve treatment targets. Consistent with previous systematic reviews (Berry &
Haddock, 2008; Ince et al., 2016) our findings suggest that high caseload, lack of protected
time and supervision prevent professionals from implementing CBTp even when training has
been provided (Jolley et al., 2012).
The role of clinical leadership is perceived as crucial in facilitating changes in service
structures responsible for effective implementation of CBTp which is corroborated by a
recent pilot study (Fornells- Ambrojo et al., 2017). Similar to previous studies (Gray et al.,
2017; Jolley et al., 2012), the findings highlight the championing nature that clinical
leadership can take in order to facilitate CBTp implementation. This would involve training
the current workforce, ensuring protected time is defined in job roles for delivery, in addition
to increasing other professionals’ awareness of the nature and purpose of CBTp.
Interestingly, participants’ reports regarding the use of quantitative as well as recovery
orientated qualitative outcome measures in measuring the effectiveness of CBTp is supported
by the recent shift in developing a CBTp adapted outcome measures (Greenwood et al., 2010)
which examine the quality of life and subjective sense of control over symptoms.
The second aim of our study involved adopting a deductive approach utilising the
NPT framework to interpret the subthemes generated from inductive coding. The subthemes
which were mapped to the construct of Coherence suggested mixed views and experiences in
56
the sense-making of CBTp. For example, although participants referred to the positive
experiences of using CBTp with clients and teams, findings suggested that the awareness of
these benefits was limited across different professional roles. Additionally, the challenges of
implementing CBTp with individuals experiencing chronic and severe distress gave rise to
the medical approach and further complicated the sense-making process.
According to Hazell et al. (2017b), professionals’ lack of belief in the efficacy of
CBTp reinforces commissioners’ lack of investment in CBTp. Similarly, the lack of
Coherence in this study might have reinforced the service level barriers which reflected the
lack of Collective Action. Furthermore, participants perceived the lack of CBTp training and
supervision as a consequence of limited service investment. Additionally, the pressure to
achieve outcomes and difficulties with referring people for psychological interventions
hindered the normalisation of CBTp. Interestingly, effective clinical leadership was
perceived as an important service level facilitator to overcome such barriers. The construct of
the Cognitive Participation indicated that participants are willing to support CBTp
implementation by increasing the inter-professional communication and consistency.
Furthermore, the Reflexive Monitoring construct suggests that participants considered
important to use a variety of outcome measures to examine the efficacy of CBTp, once it is
implemented.
Overall, the framework analysis found support for all of the constructs of the NPT.
Participants were willing to support the implementation of CBTp. However, the lack of
clarity around the purpose of CBTp among professionals and organisational level barriers
seem to impede the wider implementation and normalisation of CBTp in teams. The two
subthemes which did not map onto the NPT framework were the perceived difficulties of
people with psychosis attending consistently and the impact of the social environment.
Although these themes might be related to the lack of Coherence and Cognitive Participation
57
from the service users/carers side, it was decided not to map them to NPT constructs since
these were the perceptions of professionals rather than an experience that service users
reported themselves.
Methodological strengths and weaknesses
One of the strengths of this study was the inclusion of professionals from different
backgrounds across different levels of seniority. This was in line with NPT which intends to
capture a systemic view of implementation processes, involving both individual and
collective action. The flexibility in data collection methods increased stakeholders’
representation by providing an alternative to participants who did not wish to participate in a
focus group and vice versa. To our knowledge, using both inductive and deductive coding
was unique in CBTp implementation research. Applying NPT analysis to the subthemes
improved our understanding of the interactions between themes which were generated from
thematic analysis. To minimise the risk of forcing themes to NPT constructs, inductive
coding was completed first.
This study recruited clinicians and managers from one Health board. Thus, the
experience and views towards CBTp might vary significantly across different Health boards.
Additionally, this study recruited only participants from CMHTs and CTs. This might have
limited the generalisability of the findings as specialised services for psychosis, such as Early
Intervention (EI) teams might have different experiences regarding the implementation of
CBTp. Furthermore, the purposive sampling method in this study might have led to further
biases, as the participants who volunteered in this study might hold specific views about the
barriers and facilitators to CBTp implementation. Although attempts to minimise researchers’
bias were made, it is possible that researchers previous knowledge and experience have
affected the interpretation of themes. Given the critical realist position of this study, it is
58
plausible that other researchers might have interpreted the data differently and identified
different themes.
Implications
The findings of this study have implications for both research and clinical practice. Although
we recruited a variety of professionals, we did not compare their views based on their role.
Thus, future studies could explore the views and experiences of CBTp implementation based
on the different role of professionals in teams. Furthermore, future research could examine
the validity of the NPT framework across different samples and psychological interventions.
Given that no service users and carers were recruited in this study, future studies could
analyse the perspectives of these stakeholder groups using NPT.
In terms of clinical implications, our findings could be used by local managers to
understand the several factors that impede the normalisation of CBTp in their teams. The use
of a theoretical framework could potentially be translated into informing training agendas and
improving clinical leadership in teams. It is important to highlight that the findings might
only reflect the Scottish context of data collection and commissioning. In particular, the NPT
model of implementation in this study might need to be refined when examining funding
pathways to reflect the key stakeholders responsible for this in other mental health systems.
Based on our findings an effective clinical leadership should operate on an individual level by
improving professionals’ competence and attitudes towards CBTp. On a service level,
clinical leadership should be reflected in defined referral pathways and professional roles in
CBTp. Moreover, our findings regarding the perceived barriers to engagement highlight the
role that service users and carers have in the successful implementation of CBTp, such as
59
setting research priorities relevant to their needs, shaping research questions and sharing
knowledge to other relevant stakeholders (Gray-Burrows et al., 2018).
Conclusion
To our knowledge, this is the first study which explores the implementation of CBTp by
applying an existent implementation framework. Participants had clarity over their
expectations from using CBTp and willingness to support the wider implementation.
However, mixed views concerning the benefits and the purpose of CBTp amongst staff
hindered the implementation on an individual level. Difficulties of making sense of using
CBTp routinely were reflected on a service level by a lack of investment into CBTp, thus
maintaining the low rates of implementation. The findings further highlight the importance of
strong clinical leadership to address difficulties in sense-making and service investment in
CBTp.
60
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65
Appendices
Appendix 1.1: Journal Submission Guidelines
Psychology and Psychotherapy: Theory, Model and Research submission guidelines
Author Guidelines
Psychology and Psychotherapy: Theory Research and Practice (formerly The British Journal
of Medical Psychology) is an international scientific journal with a focus on the
psychological aspects of mental health difficulties and well-being; and psychological
problems and their psychological treatments. We welcome submissions from mental health
professionals and researchers from all relevant professional backgrounds. The Journal
welcomes submissions of original high quality empirical research and rigorous theoretical
papers of any theoretical provenance provided they have a bearing upon vulnerability to,
adjustment to, assessment of, and recovery (assisted or otherwise) from psychological
disorders. Submission of systematic reviews and other research reports which support
evidence-based practice are also welcomed, as are relevant high quality analogue studies. The
Journal thus aims to promote theoretical and research developments in the understanding of
cognitive and emotional factors in psychological disorders, interpersonal attitudes, behaviour
and relationships, and psychological therapies (including both process and outcome research)
where mental health is concerned. Clinical or case studies will not normally be considered
except where they illustrate particularly unusual forms of psychopathology or innovative
forms of therapy and meet scientific criteria through appropriate use of single case
experimental designs.
All papers published in Psychology and Psychotherapy: Theory, Research and Practice are
eligible for Panel A: Psychology, Psychiatry and Neuroscience in the Research Excellence
Framework (REF).
1. Circulation
The circulation of the Journal is worldwide. Papers are invited and encouraged from authors
throughout the world.
2. Length
All articles submitted to PAPT must adhere to the stated word limit for the particular article
type. The journal operates a policy of returning any papers that are over this word limit to the
authors. The word limit does not include the abstract, reference list, figures and tables.
Appendices however are included in the word limit. The Editors retain discretion to publish
papers beyond this length in cases where the clear and concise expression of the scientific
content requires greater length (e.g., a new theory or a new method). The authors should
contact the Editors first in such a case.
Word limits for specific article types are as follows:
66
• Research articles: 5000 words
• Qualitative papers: 6000 words
• Review papers: 6000 words
• Special Issue papers: 5000 words
3. Brief reports
These should be limited to 1000 words and may include research studies and theoretical,
critical or review comments whose essential contribution can be made briefly. A summary of
not more than 50 words should be provided.
4. Submission and reviewing
All manuscripts must be submitted via Editorial Manager. The Journal operates a policy of
anonymous (double blind) peer review. We also operate a triage process in which
submissions that are out of scope or otherwise inappropriate will be rejected by the editors
without external peer review to avoid unnecessary delays. Before submitting, please read
the terms and conditions of submission and the declaration of competing interests. You may
also like to use the Submission Checklist to help you prepare your paper. If you need more
information about submitting your manuscript for publication, please email Melanie Seddon,
Senior Editorial Assistant at [email protected] or phone +44 (0) 1243 770 108
5. Manuscript requirements
• Contributions must be typed in double spacing with wide margins. All sheets must be
numbered.
•Manuscripts should be preceded by a title page which includes a full list of authors and their
affiliations, as well as the corresponding author's contact details. You may like to
use this template. When entering the author names into Editorial Manager, the corresponding
author will be asked to provide a CRediT contributor role to classify the role that each author
played in creating the manuscript. Please see the Project CRediTwebsite for a list of roles.
• The main document must be anonymous. Please do not mention the authors’ names or
affiliations (including in the Method section) and refer to any previous work in the third
person.
• Tables should be typed in double spacing, each on a separate page with a self-explanatory
title. Tables should be comprehensible without reference to the text. They should be placed at
the end of the manuscript but they must be mentioned in the text.
• Figures can be included at the end of the document or attached as separate files, carefully
labelled in initial capital/lower case lettering with symbols in a form consistent with text use.
Unnecessary background patterns, lines and shading should be avoided. Captions should be
listed on a separate sheet. The resolution of digital images must be at least 300 dpi. All
figures must be mentioned in the text.
• For articles containing original scientific research, a structured abstract of up to 250 words
should be included with the headings: Objectives, Design, Methods, Results, Conclusions.
Review articles should use these headings: Purpose, Methods, Results, Conclusions.
67
• All Articles must include Practitioner Points – these are 2-4 bullet points, in addition to the
abstract, with the heading ‘Practitioner Points’. These should briefly and clearly outline the
relevance of your research to professional practice.
• For reference citations, please use APA style. Particular care should be taken to ensure that
references are accurate and complete. Give all journal titles in full and provide DOI numbers
where possible for journal articles.
• SI units must be used for all measurements, rounded off to practical values if appropriate,
with the imperial equivalent in parentheses.
• In normal circumstances, effect size should be incorporated.
• Authors are requested to avoid the use of sexist language.
• Authors are responsible for acquiring written permission to publish lengthy quotations,
illustrations, etc. for which they do not own copyright.
• Manuscripts describing clinical trials must be submitted in accordance with the CONSORT
statement on reporting randomised controlled trials (http://www.consort-statement.org).
• Manuscripts describing systematic reviews and meta-analyses must be submitted in
accordance with the PRISMA statement on reporting systematic reviews and meta-analyses
(http://www.prisma-statement.org).
For guidelines on editorial style, please consult the APA Publication Manual published by the
American Psychological Association.
6. Multiple or Linked submissions
Authors considering submitting two or more linked submissions should discuss this with the
Editors in the first instance.
7. Supporting Information
PAPT is happy to accept articles with supporting information supplied for online only
publication. This may include appendices, supplementary figures, sound files, videoclips etc.
These will be posted on Wiley Online Library with the article. The print version will have a
note indicating that extra material is available online. Please indicate clearly on submission
which material is for online only publication. Please note that extra online only material is
published as supplied by the author in the same file format and is not copyedited or typeset.
Further information about this service can be found
at http://authorservices.wiley.com/bauthor/suppmat.asp
8. Copyright and licenses
If your paper is accepted, the author identified as the formal corresponding author for the
paper will receive an email prompting them to login into Author Services, where via the
Wiley Author Licensing Service (WALS) they will be able to complete the license agreement
on behalf of all authors on the paper.
For authors signing the copyright transfer agreement
68
If the OnlineOpen option is not selected the corresponding author will be presented with the
copyright transfer agreement (CTA) to sign. The terms and conditions of the CTA can be
previewed in the samples associated with the Copyright FAQs.
For authors choosing OnlineOpen
If the OnlineOpen option is selected the corresponding author will have a choice of the
following Creative Commons License Open Access Agreements (OAA):
- Creative Commons Attribution Non-Commercial License OAA
- Creative Commons Attribution Non-Commercial -NoDerivs License OAA
To preview the terms and conditions of these open access agreements please visit
the Copyright FAQs and you may also like to visit the Wiley Open Access and Copyright
Licence page.
If you select the OnlineOpen option and your research is funded by The Wellcome Trust and
members of the Research Councils UK (RCUK) or Austrian Science Fund (FWF) you will be
given the opportunity to publish your article under a CC-BY license supporting you in
complying with your Funder requirements. For more information on this policy and the
Journal’s compliant self-archiving policy please visit our Funder Policy page.
9. Colour illustrations
Colour illustrations can be accepted for publication online. These would be reproduced in
greyscale in the print version. If authors would like these figures to be reproduced in colour
in print at their expense they should request this by completing a Colour Work Agreement
form upon acceptance of the paper. A copy of the Colour Work Agreement form can be
downloaded here.
10. Pre-submission English-language editing
Authors for whom English is a second language may choose to have their manuscript
professionally edited before submission to improve the English. A list of independent
suppliers of editing services can be found
athttp://authorservices.wiley.com/bauthor/english_language.asp. All services are paid for and
arranged by the author, and use of one of these services does not guarantee acceptance or
preference for publication.
11. OnlineOpen
OnlineOpen is available to authors of primary research articles who wish to make their article
available to non-subscribers on publication, or whose funding agency requires grantees to
archive the final version of their article. With OnlineOpen, the author, the author's funding
agency, or the author's institution pays a fee to ensure that the article is made available to
non-subscribers upon publication via Wiley Online Library, as well as deposited in the
funding agency's preferred archive. For the full list of terms and conditions,
see http://wileyonlinelibrary.com/onlineopen#OnlineOpen_Terms
Any authors wishing to send their paper OnlineOpen will be required to complete the
payment form available from our website at:https://onlinelibrary.wiley.com/onlineOpenOrder
69
Prior to acceptance there is no requirement to inform an Editorial Office that you intend to
publish your paper OnlineOpen if you do not wish to. All OnlineOpen articles are treated in
the same way as any other article. They go through the journal's standard peer-review process
and will be accepted or rejected based on their own merit.
12. Author Services
Author Services enables authors to track their article – once it has been accepted – through
the production process to publication online and in print. Authors can check the status of their
articles online and choose to receive automated e-mails at key stages of production. The
author will receive an e-mail with a unique link that enables them to register and have their
article automatically added to the system. Please ensure that a complete e-mail address is
provided when submitting the manuscript. Visit http://authorservices.wiley.com/bauthor/ for
more details on online production tracking and for a wealth of resources including FAQs and
tips on article preparation, submission and more.
13. The Later Stages
The corresponding author will receive an email alert containing a link to a web site. A
working e-mail address must therefore be provided for the corresponding author. The proof
can be downloaded as a PDF (portable document format) file from this site. Acrobat Reader
will be required in order to read this file. This software can be downloaded (free of charge)
from the following web site:http://www.adobe.com/products/acrobat/readstep2.html. This
will enable the file to be opened, read on screen and annotated direct in the PDF. Corrections
can also be supplied by hard copy if preferred. Further instructions will be sent with the
proof. Hard copy proofs will be posted if no e-mail address is available. Excessive changes
made by the author in the proofs, excluding typesetting errors, will be charged separately.
14. Early View
Psychology and Psychotherapy is covered by the Early View service on Wiley Online
Library. Early View articles are complete full-text articles published online in advance of
their publication in a printed issue. Articles are therefore available as soon as they are ready,
rather than having to wait for the next scheduled print issue. Early View articles are complete
and final. They have been fully reviewed, revised and edited for publication, and the authors’
final corrections have been incorporated. Because they are in final form, no changes can be
made after online publication. The nature of Early View articles means that they do not yet
have volume, issue or page numbers, so they cannot be cited in the traditional way. They are
cited using their Digital Object Identifier (DOI) with no volume and issue or pagination
information. E.g., Jones, A.B. (2010). Human rights Issues. Human Rights Journal. Advance
online publication. doi:10.1111/j.1467-9299.2010.00300.x
Further information about the process of peer review and production can be found in this
document. What happens to my paper? Appeals are handled according to the procedure
recommended by COPE.
70
Appendix 1.2: Quality Appraisal of included studies
Table
Quality appraisal of included studies. Red colour = domain absent, Yellow =domain partially met, Green = domain fully met
Scope
&
Purpose
Design Sampling
Strategy
Analysis Interpretation Reflexivity Ethical
Dimensions
Relevance
and
Transferabi
lity
Dunn et al., 2002
Hazell et al., 2007
Iredale et al., 2015
Landau, S &
Ruddle, A. (2017)
Li et al., 2017
McGowan et al.,
2005
Messari & Hallam
2003
71
Naeem et al., 2016
Newton et al., 2007
Prytys et al., 2011
Waller et al., 2015
72
Appendix 1.3: List of overarching themes
Codes Subthemes Overarching themes
• Culture & Religion beliefs about mental
health
• Stigma
• Fear of deterioration
• Sense of control/ attributions
• Cognitive difficulties
• Disbelief in recovery
• Family’s perceptions
Motivation to engage
Difficulties in seeking
treatment
• Accessible language of treatment
materials
• Awareness of treatment options
• traveling distance/expenses
• Housebound
Practical difficulties in
accessing treatment
• Lack of training
• Pessimistic views about psychological
interventions
• Pessimistic views about recovery
• Professional’s confidence in delivering
therapy
• Lack of sustaining benefits from
treatment
Professionals’ confidence
in delivering therapy
73
• Challenges of working with complex
and chronic illness
• Difficulties of working with
comorbidity
• Difficulties in managing endings
• Challenges of sticking to the treatment
protocol
• Cultural/ Religious awareness
• High Dropout rates
• Family’s engagement
• Engagement with therapy (attendance,
compliance with homework, sense of
control that patients have)
• Dominance of the medical model
• Disbelief in clinical guidelines
• Lack of clarity around suitability
criteria
• Lack of defined professional roles
• Need for a specialised trained therapist
• cognitive difficulties
• Lack of common agenda between
therapists and client
• Therapist becoming incorporated into
the delusional system of the client
Practical difficulties
Challenges of providing care
• Time restraints
• Lack of training availability
74
• Long waiting list
• Supervision
• Lack of specific job roles
Resources
Service design
• Unclear pathways
• Target driven services
• Lack of confidence in investing in
CBTp
• Deciding suitability
• Medical model dominance
Conflicting needs
75
Appendix 1.4: Walsh & Downe (2006) Quality Appraisal Framework
Scoring key: Not present = 0 Partially present = 1 Present = 2
Stages Essential Criteria Specific prompts Score
Score and Purpose Clear statement of, and
rationale for, research
question/aims/purposes
Study thoroughly
contextualised by existing
literature
• Clarity of focus demonstrated
• Explicit purpose given, such as descriptive/explanatory
intent, theory building, hypothesis testing
• Link between research and existing knowledge
demonstrated
Design Method/design apparent, and
consistent with research intent
Data collection strategy
apparent and appropriate
• Rationale given for use of qualitative design
• Discussion of epistemological/ontological grounding
• Rationale explored for specific qualitative method (e.g.
ethnography, grounded theory, phenomenology)
• Discussion of why particular method chosen is most
appropriate/sensitive/relevant for research question/aims
• Setting appropriate
• Were data collection methods appropriate for type of data
required and for specific qualitative method?
• Were they likely to capture the complexity/diversity of
experience and illuminate context in sufficient detail?
• Was triangulation of data sources used if appropriate?
76
Sampling Strategy Sample and sampling method
appropriate
• Selection criteria detailed, and description of how
sampling was undertaken
• Justification for sampling strategy given
• Thickness of description likely to be achieved from
sampling
• Any disparity between planned and actual sample
explained
77
Analysis Analytic approach appropriate
• Approach made explicit (e.g. Thematic distillation,
constant comparative method, grounded theory)
• Was it appropriate for the qualitative method chosen?
• Was data managed by software package or by hand and
why?
• Discussion of how coding systems/conceptual
frameworks evolved
• How was context of data retained during analysis
• Evidence that the subjective meanings of participants
were portrayed
• Evidence of more than one researcher involved in stages
if appropriate to epistemological/theoretical stance
• Did research participants have any involvement in
analysis (e.g. member checking)
• Evidence provided that data reached saturation or
discussion/rationale if it did not
• Evidence that deviant data was sought, or discussion/
rationale if it was not
78
Interpretation Context described and taken
account of in interpretation
Clear audit trail given
Data used to support
interpretation
• Description of social/physical and interpersonal
contexts of data collection
• Evidence that researcher spent time ‘dwelling with the
data’, interrogating it for competing/alternative
explanations of phenomena
• Sufficient discussion of research processes such that
others can follow ‘decision trail’
• Extensive use of field notes entries/verbatim interview
quotes in discussion of findings
• Clear exposition of how interpretation led to
conclusions
Reflexivity Researcher reflexivity
demonstrated
• Discussion of relationship between researcher and
participants during fieldwork
• Demonstration of researcher’s influence on stages of
research process
• Evidence of self-awareness/insight
• Documentation of effects of the research on researcher
• Evidence of how problems/complications met were
dealt with
79
Ethical
Dimensions
Demonstration of sensitivity to
ethical concerns • Ethical committee approval granted
• Clear commitment to integrity, honesty, transparency,
equality and mutual respect in relationships with
participants
• Evidence of fair dealing with all research participants
• Recording of dilemmas met and how resolved in
relation to ethical issues
• Documentation of how autonomy, consent,
confidentiality, anonymity were managed
Relevance and
transferability
Relevance and
transferability evident
• Sufficient evidence for typicality specificity to be
assessed
• Analysis interwoven with existing theories and other
relevant explanatory literature drawn from similar
settings and studies Discussion of how explanatory
propositions/emergent theory may fit other contexts
• Limitations/weaknesses of study clearly outlined
• Clearly resonates with other knowledge and
experience
• Results/conclusions obviously supported by evidence
• Interpretation plausible and ‘makes sense’
• Provides new insights and increases understanding
• Significance for current policy and practice outlined
• Assessment of value/empowerment for participants
• Outlines further directions for investigation
• Comment on whether aims/purposes of research were
achieved
Total score
80
Appendix 1.5: Search terms for Systematic Review
EMBASE (n=132) and Psychinfo (n =233)
(CBTp or CBT or Cognitive Behavioural therapy or Cognitive Behaviour Therapy). ab.OR
(CBTp or CBT or Cognitive Behavioural therapy or Cognitive Behaviour Therapy). kw. OR
(CBTp or CBT or Cognitive Behavioural therapy or Cognitive Behaviour Therapy).ti.
AND
(schizophren* or psychos*).ab. OR (schizophren* or psychos*).kw. OR (schizophren* or
psychos*).ti.
AND
(NICE or “National Institute for Health and Care Excellence” or implement* or guideline*)
ab OR (NICE or “National Institute for Health and Care Excellence” or implement* or
guideline*) kw. OR (NICE or “National Institute for Health and Care Excellence” or
implement* or guideline*). ti.
CINAHL (n =60)
CBTp or CBT or Cognitive Behavioural therapy or Cognitive Behaviour Therapy).ab. OR
(CBTp or CBT or Cognitive Behavioural therapy or Cognitive Behaviour Therapy).ti.
AND
(schizophren* or psychos*).ab. OR (schizophren* or psychos*).ti.
AND
(NICE or “National Institute for Health and Care Excellence” or implement* or
guideline*).ab. OR (NICE or “National Institute for Health and Care Excellence” or
implement* or guideline*). ti.
81
Pubmed (n= 172)
CBT[Title/Abstract] OR CBTp [Title/Abstract] OR Cognitive Behaviour Therapy
[Title/Abstract] OR Cognitive Behavioural Therapy [Title/Abstract]
AND
Schizophren* [Title/Abstract] OR psychos*[Title/Abstract]
AND
NICE[Title/Abstract] OR “national institute for health and care excellence” [Title/Abstract]
OR implement* [Title/Abstract] OR guideline*[Title/Abstract]
MEDLINE (n =347)
TOPIC: (CBT OR CBTp OR Cognitive behavioural therapy OR Cognitive behaviour
Therapy)
AND
TOPIC: (schizophren* or Psychos*)
AND
TOPIC: (NICE OR “national institute for health and care excellence” OR implement* OR
guideline*)
82
Appendix 2.1 Major Research Project Proposal
Abstract
Background: In contrast to national guidelines, evidence suggest that only a minority of
service users experiencing psychosis have access to Cognitive Behavioural Therapy for
psychosis (CBTp). Although previous studies identified various barriers to implementation of
CBTp, they did not use a theoretical framework to interpret them.
Aims: This study aims to utilize Normalisation Process Theory (NPT) to explore the
experiences and perspectives of stakeholders regarding the implementation of CBTp in NHS
A&A.
Method: The sample will consist of Community Mental Health Team (CMHT) managers and
professionals working with people who experienced psychosis, service users with lived
experience of psychosis and their carers. This study will adopt a qualitative design using
focus groups and semi-structured individual interviews with nursing staff, occupational
therapist, clinical psychologists, psychiatrists, service users and carers. Transcribed
interviews will be analysed using Framework Analysis (deductive) and Thematic Analysis
(inductive methods).
Applications: To our knowledge the use of a theoretical framework and the participation of
recipients and providers of CBTp to explore the barriers to implementation, constitutes an
innovative feature of this study in comparison with previous studies. Potential implication of
this study would involve the generation of a plausible intervention plan to overcome
implementation barriers in service and individual level.
83
Introduction
Psychosis constitutes a spectrum of mental distress which is often classified into positive and
negative symptoms (American Psychiatric Association [APA], 2013). Positive symptoms,
refer to experiences such as hearing voices or seeing things that others cannot see or hear
(‘hallucinations’), speaking in a way that others find hard to follow (‘thought disorder’) and
holding firm beliefs that seem unusual to others (‘delusions’). Negative symptoms refer to
lack of enjoyment (anhedonia), motivation (apathy) and diminished emotional expression
(APA, 2013).
Cognitive Behavioural Therapy for psychosis (CBTp) is an individually tailored talking
therapy which aims to increase an individual’s coping with specific psychotic experiences
(e.g. hearing distressing voices) by modifying associated thoughts, physical sensations,
behaviours and emotions (National Institute of Clinical Excellence; NICE, CG178, 2014).
Recent meta-analyses indicate that CBTp not only contributes to the reduction in positive
symptoms, improves medication adherence and general functioning (Turner, van der Gaag,
Karyotaki, & Cuipers, 2014; Wykes, Steel, Everitt, & Tarrier, 2008) but it is also associated
with reduced risk of transition to psychosis for individuals with elevated risk (Hutton &
Taylor, 2014)
Wykes et al (2008) meta-analysis of CBTp Randomised Control Trials (RCTs) estimated the
mean effect size for specific psychotic experiences, depression and social anxiety to be in the
medium range; it also indicated that low quality trials had inflated effect sizes. Main
contributor to effect size inflation was lack of blinding. However, a more recent meta-
analysis (Jauhar et al. 2014) reported that the effect sizes of CBTp further reduced from
medium to small range by controlling for the blinding bias. Jauhar et al (2014) argued that
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design quality scales and effect size calculation methods used in previous meta-analysis of
CBTp (e.g. Wykes et al, 2008) had contributed to inflated effect sizes.
For context, a recent meta-analysis (Leucht et al. 2009) of first and second generation
antipsychotic medication estimated the effect sizes to range from small to medium range for
overall symptoms. As with CBTp studies, the effectiveness on positive symptoms was less,
with effect sizes ranging from small to moderate range. Furthermore, both NICE (2014) and
the Scottish Intercollegiate Guidelines Network (SIGN (131), 2013), recommend CBTp to be
offered to all individuals experiencing psychosis over the course of at least 16 sessions.
However, evidence suggest that even low intensity CBTp (mean number of session was 9),
has medium effect sizes post intervention and at follow up (Hezell, Hayward, Cavanagh, &
Strauss, 2016)
Despite the national guidelines for CBTp, evidence indicates limited accessibility, estimating
that only five to nine percent of service users has access to CBTp (Berry & Haddock, 2008;
Haddock et al. 2014; Prytus, Garety, Jolley, Onwumere & Craig, 2011). Previous studies
reported lack of training, allocated time and supervision as barriers to CBTp implementation
(Berry & Haddock, 2008). Even when the rates of staff training increased, the provision for
allocated time and supervision continued to affect negatively the implementation of CBTp
(Jolley et al. 2012). Prytus et al. (2011) identified increased caseloads, lack of resources and
staff attitudes towards the efficacy of psychological therapy as the most significant barriers to
CBTp implementation. A recent systematic review (Ince, Haddock, & Tai, 2016) indicated
organisational barriers (e.g. lack of resources, protected time, supervision and specialist
training) as the most commonly reported followed by barriers met by staff (e.g. biological
model of psychosis, lack of clarity of who should be offered treatment, disbelief in
psychological interventions) and service users (e.g. poor engagement, overly medicated or
symptomatic to take part in therapy). Furthermore, the reduced effect sizes that were found in
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the latest meta-analysis, provoked a debate among clinicians regarding the efficacy of CBTp
(e.g. McKenna & Kingdon, 2014), which has affected the consensus regarding prioritisation
of resources.
Normalisation Process Theory (NPT; May et al, 2009; Murray et al, 2010) is one of the
theoretical frameworks that were developed as an attempt to explain the gaps observed in
applying evidenced based treatments in routine practice and influencing health related
policies (Murray et al, 2010). The theory focuses on the implementation of interventions,
their embedding in routine practice and the processes by which interventions are sustained or
normalised. NPT consists of four components which attempt to explore the implementation,
embedding and incorporation of interventions among stakeholders. The first component,
coherence refers to the sense of clear and common purpose of the intervention between the
stakeholders. Cognitive participation refers to the degree to which stakeholders perceive the
potential benefits of the intervention before it is implemented. Consequently, collective
action refers to stakeholder’s readiness to change their current practice due to the
implementation of the intervention. The fourth component, reflective action refers to the
potential experience of the stakeholders after the intervention has been applied (May et al
2009; Murray et al; 2010).
Although previous studies identified various implementation barriers of CBTp, none of them
utilised an existent m interpret and formulate such barriers in organisational and individual
level. This might have limited the understanding regarding the interaction between
experiences and perspectives of stakeholders, which subsequently restricted the generation of
an intervention plan based on theoretical model used, to overcome such barriers.
Aims/Hypotheses
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The proposed research aims to utilize NPT to explore the experiences and perspectives of
stakeholders (NHS mental health managers and staff, service users and carers) regarding the
implementation of CBTp in NHS Ayrshire and Arran (A&A).
Research questions
1. How do the managers and staff working with people experiencing psychosis make
sense of CBTp implementation?
2. What are service user’s experiences of accessing CBTp?
3. What are carers’ experiences of their loved one’s access to CBTp?
4. Can stakeholder’s perspectives be understood within the NPT framework?
Methodology
Design
This study will adopt a qualitative design, as we aim to examine individuals’ experience as
phenomenon, within the context and social reality of participants (Holloway, 1997). Focus
groups and semi-structured individual interviews will be employed, and analysed using both
deductive and inductive methods.
Epistemology
The epistemological positions behind this study follow the critical realist and post-positivist
paradigms, suggesting that the experience of participants is influenced by the social,
structural and political context in which the study is conducted (Danermark, Ekström,
Jakobsen, & Karlsson, 2002). We invite participants to take perspectives based on their roles
either as potential referrers for CBTp, providers of CBTp or consumers of CBTp. Stryker
(2008) proposes that individuals take on ‘positions’, which are recognized social categories.
The concept of ‘role’ is then defined as the set of expectations attributed to those positions.
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Thus, we assume that the context of ‘role’ will be an important social factor which affects the
experience and the perspectives of the participants (Appendix D).
Participants
The sample will consist of nursing staff, occupational therapist, clinical psychologists and
psychiatrists working with people who experienced psychosis, service users with lived
experience of psychosis and their carers. Staff will be recruited from CMHTs across the three
geographical regions in NHS A&A (East, South, North). Service users and carers would be
recruited from third sector organisations in Ayrshire.
Inclusion and exclusion criteria will be applied flexibly to get a heterogeneous sample, as we
are aiming to get a broad perspective of experiences. CMHT’s staff must have worked with
individuals who have experienced psychosis. Service users, must have an experience of
psychosis which led to CMHT involvement and reside in Ayrshire to participate; carers must
have/had a caring role for someone with lived experience of psychosis.
Third sector organisations will be informed about the aims of the study, and consent to
contact their members will be sought. Carers and service users will be provided with
introductory information sheets from third sector organisation, which will briefly outline the
aims and eligibility to participate in the study. Following contact with the researcher,
potential participants will receive a participant information sheet. Before taking part,
participants will provide written informed consent. Participants will then provide their contact
details to the researcher to arrange the date, time and location of the focus group or interview
as appropriate.
In order to recruit CMHT staff and managers, study information will be sent via email to the
CMHTs managers to circulate to team members . This will be followed by a telephone call to
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arrange for the researcher to attend team meetings to introduce the study and provide
participant information sheets. Before taking part, participants will provide written informed
consent.
Based on previous studies (e.g. Bird et al. 2014) with similar research design we estimate that
we will need seven focus groups with six to eight participants per group to reach thematic
saturation and ensure stakeholder’s representation. Potential barriers to recruitment involve
lack of motivation to attend group contexts and time restrains (see Appendix E).
Materials
Data collection will involve: a) The completion of basic demographics questionnaire (e.g.
age, gender, occupational status etc.) b) separate focus groups with nursing staff and
occupational therapists, psychiatrist, clinical psychologist, service users and carers which will
last approximately one hour. Secondary option of individual interviews will be available for
participants who have difficulties attending a group context, as previous study has
recommended this to increase participation (e.g. Farrelly et al, 2015).
Analysis
Framework Analysis (FA; Ritchie & Spencer, 1994) will used for the data analysis given that
a theoretical framework (NPT) will be utilised in this study to explore the experiences of
stakeholders. The interview topic guide will be designed to permit participants to reflect on
the NPT components, related to experiences of accessing (service users/carers) /implementing
(staff) CBTp. Subsequently, themes generated from the analysis of the transcripts will be
compared and then matched with the NPT components (deductive coding).
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Thematic Analysis (Braun & Clarke, 2006) will be also used to identify deviant or new
themes that might not be adequately captured in the deductive framework. Thus, the
inductive coding will limit the possibility of themes not fitting the NPT framework, being
reframed or undetected.
The analytic process will follow the five-stage model (Ritchie &Spencer,1994), which
involves familiarisation, thematic framework development, indexing data, charting and
mapping. Anonymised transcripts will be imported to Nvivo (version 7, QRS international)
for analysis. The produced coding manual will be given to a colleague to examine differences
in coding (inter-rated reliability).
Health and Safety issues
Participants will have the right to withdraw at any point during the interview. The researcher
will not be directly responsible for the care of those being recruited. As part of the informed
consent process, participants will be informed of how to access support should they
experience distress following the interview.
Interviews with service users and carers, will take place at third sector organisation grounds
during working hours. The location and the estimated time of the interviews will be
documented in advance so that research team can contact the researcher before and after the
estimated end. Researcher will have access to risk minimisation procedures of the settings
that the interviews will take place (Appendix B)
Ethical considerations
Participants will be asked to read an information sheet, which will summarise the procedure
of the study, the right of withdrawal and confidentiality. Before taking part, participants will
provide written informed consent. Although, participants will have the right to withdraw at
90
any stage of the study, anonymised data already collected will be retained. Participants will
be informed that if the research team is concerned for their safety or the safety of other
people, they may be required to break confidentiality after informing and explaining them the
reasons for this decision.
Interviews’ transcripts will be stored in encrypted files in a password protected computer in
line with the University of Glasgow and NHS A&A data protection guidelines. Anonymity
will be kept by changing the names mentioned in the interviews while confidentiality issues
will be managed by the destruction of the audio material after the completion of the study.
Favourable ethical approval will be sought via the University of Glasgow, Ethics Committee
and NHS A&A Research and Development Department.
Time-Line
Time Major Task/s
January Submission of MRP proposal.
May 2017 Submission for University Ethics approval
June 2017 Ethics Meeting
Submission for NHS A & A Research and Development
Department approval
August 2017-January
2018
Recruitment of participants
February – April 2018 Transcriptions of interviews.
Data analysis.
April– July 2018 MRP write up
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Financial cost
Participation in this study is voluntary. Financial expenses involve stationary cost, postage,
travel expenses for participants and the software for the analysis of the data (Appendix A).
The digital recorder for the interviews will be borrowed from the University.
Practical application
To our knowledge, the use of a theoretical framework and the participation of recipients and
providers of CBTp, constitutes a distinctive feature of this study in comparison with previous
studies in this research field. Potential implication of this study would involve the generation
of a plausible intervention plan to overcome implementation barriers in service and individual
level.
92
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Bird, V., Leamy, M., Tew, J., Boutillier, C. L., Williams, J., & Slade, M. (2014). Fit for
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Jolley, S., Onwumere, J., Kuipers, E., Craig, T., Moriatry, A., & Garety, P. (2012). Increasing
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(2010). Normalisation process theory: a framework for developing, evaluating
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Appendix 2.2: Rationale for amendments to initial research proposal
Although, the initial aims of the study were to recruit service users, professionals and carers,
researchers decided to focus recruitment on mental health professionals only. The rationale
for this decision was related to the feasibility of completing the study within the given
timescale. Additionally, focusing on one stakeholder group helped us to reach thematic
saturation and get perspectives from a variety of professional groups. The receipt of further
feedback from key stakeholders (including clinical psychology) which was not forwarded to
the researcher by NHS Ayrshire and Arran clinical psychology governance committee
suggested further amendment to initial proposal. The overall feedback advised that
researchers should consider broadening the scope of the focus groups and include a
discussion around the provision of psychosocial interventions in general for people with
schizophrenia while retaining the focus on CBTp specifically.
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Appendix 2.3: MVLS ethics committee approval
Dear Professor Andrew Gumley MVLS College Ethics Committee Project Title: Exploring the implementation of Cognitive Behavioural Therapy for Psychosis using Normalisation Process Theory Framework Project No: 200160151
The College Ethics Committee has reviewed your application and has agreed that there is no objection on ethical grounds to the proposed study. We are happy therefore to approve the project, subject to the following conditions:
• I note the response from NHS REC. The study will now exclusively focus on staff. Consent and information sheets for service users and carers are still on the system but will not be used.
• The applicants have been advised by NHS REC to submit IRAS paperwork to facilitate local Research and Development approvals. While not mandatory for ethical approval, these documents should be submitted to MVLS ethics.
• Project end date as stipulated in original application.
• The data should be held securely for a period of ten years after the completion of the research project, or for longer if specified by the research funder or sponsor, in accordance with the University’s Code of Good Practice in Research:
(http://www.gla.ac.uk/media/media_227599_en.pdf)
• The research should be carried out only on the sites, and/or with the groups defined in the application.
• Any proposed changes in the protocol should be submitted for reassessment, except when it is necessary to change the protocol to eliminate hazard to the subjects or where the change involves only the administrative aspects of the project. The Ethics Committee should be informed of any such changes.
• You should submit a short end of study report to the Ethics Committee within 3 months of completion.
Yours sincerely
Dr Terry Quinn
98
Appendix 2.4: Research and Development Department Approval
99
100
101
Appendix 2.5: Amendments approval from R&D
102
Appendix 2.6: Information leaflet
DISCO: Discovering Implementation in health Services of COgnitive Behaviour
Therapy for psychosis
Volunteers are needed for a research study which would involve a focus group regarding your
experiences of referring or offering psychosocial interventions and CBTp to people who
experience psychosis. The focus group is expected to last one and half hours and will take
place at NHS Ayrshire &Arran grounds, at a time convenient for you.
If you have any queries and/or are interested in participating contact us directly by email
[email protected] to arrange a time and a place convenient for you to attend.
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Appendix 2.7: Participant Information Sheet
Participant Information Sheet (Version 1.3, 13th of November 2017)
Discovering Implementation in health Services of COgnitive Behaviour
Therapy for psychosis (DISCO)
Part 1 What does my participation involve?
1 Introduction
You are invited to take part in this research project because you are currently an adult mental
health operational manager, occupational therapist, a member of nursing staff, nursing
assistant, clinical psychologist or psychiatrist working in Community Mental Health Services
(CMHT) or Crisis Team (CT) in NHS Ayrshire & Arran (NHS AA).
This Participant Information and Consent Form outlines the details of the research project,
including the procedures involved, and will help you decide if you want to take part in the
research.
Please read this information carefully. Ask questions about anything that you do not
understand, or would like to learn more about. Before deciding whether or not to take part,
you might want to talk about it with a colleague. Participation in this research is voluntary. If
you don’t wish to take part, you don’t have to. Your employment at NHSAA will not be
affected whether you take part or not.
If you decide you want to take part in the research project, you will be asked to sign the
consent section. By signing it you are telling us that you:
• Understand what you have read
• Consent to take part in the research project
• Consent to the use of your personal information as described.
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You will be given a copy of this Participant Information and Consent Form to keep.
2 What is the purpose of this research?
The project is funded by the University of Glasgow, Institute of Health and Wellbeing and
NHS Ayrshire & Arran Research and Development Service.
Psychosocial interventions (e.g. psychoeducation, social skills training) can assist individuals
experiencing psychosis to cope better with their symptoms and improve general functioning.
One of the psychologically informed intervention for psychosis is Cognitive Behavioural
Therapy for psychosis (CBTp). Cognitive Behavioural Therapy for psychosis (CBTp) is a
talking therapy which aims to increase coping with distressing psychotic experiences (e.g.
hearing distressing voices) by changing the way that someone interprets, feels and reacts to
them. Evidence suggests that CBTp is effective in reducing distressing psychotic experiences
and improves general functioning.
The aim of this study is to understand the perspectives of mental health staff that might
influence our understanding of the implementation of psychosocial interventions and CBTp .
This potentially will help us improve the accessibility of psychosocial interventions and
CBTp, which has shown to be effective for people experiencing psychosis and is
recommended by national guidelines. Participants will be invited to share their views and
experiences of psychosocial interventions and CBTp being offered to service users with
psychosis.
3 What does participation in this research involve?
Participation in this study involves: attending a focus group with other mental health staff
members. We expect that the focus groups would have maximum 6-8 participants. In case
you are unable to attend group settings, an option for individual interviews will be available.
The focus groups are planned to take place in NHS AA grounds in East, South and North
Ayrshire.
Professional mental health care staff who partake in the study will be asked about their
experiences/views of psychosocial interventions being offered to people with psychosis
Additionally, participants will be asked about their experiences of CBTp being offered (e.g.
referring people for CBTp, their experience of delivery of CBTp by others or their experience
of offering CBTp themselves). It will also include their views regarding implementation of
CBTp in NHSAA.
It is expected that the interview will require about 1 – 1.5 hrs of your time.
4 Other relevant information about the research project
We will invite mental health staff of all disciplines from CMHTs and CT’s of NHS AA to
participate in separate focus groups.
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The allocation to focus groups will be based on your professional grouping. For instance, if
you are a member of a nursing staff you will be allocated to a focus group which consist only
of nursing staff professional, if you are clinical psychologist, you will be allocated to
psychology focus group and if you are psychiatrist you will allocated to a psychiatry focus
group. This is so that we can capture distinctive perspectives based on professional roles
within the organisation. In case you are unable to participate in group settings, option for
individual interview will be also available.
5 Do I have to take part in this research project?
No, participation in any research project is voluntary. If you do not wish to take part you do
not have to. If you decide to take part and later change your mind that is also OK. You have
the right to withdraw from the project at any stage.
If you do decide to take part, you will be given this Participant Information Sheet and a
Consent Form to sign and you will be given a copy to keep.
Your decision whether to take part or not, or to take part and then withdraw, will not affect
your employment with NHS AA.
6 What are the possible benefits of taking part?
There are no particular benefits to you in taking part. The research is led by a research group
with a track record of research and training in psychological therapies for recovery from
psychosis. We hope that these data will be used to inform policy and practice development
both locally and more broadly in NHS Scotland.
7 What are the possible risks and disadvantages of taking part?
We do not anticipate any significant risks associated with participation in this project.
8 What if I withdraw from this research project?
You can withdraw from the study at any time. You do not have to provide a reason and if you
withdraw your employment will not be affected.
If you do withdraw from the study, any personally identifiable information about you will be
destroyed. However, anonymised data already collected will be retained to ensure that the
results of the research project can be measured properly and to comply with law. You should
be aware that data collected by the research team up to the time that you withdraw will form
part of the research project results. If you do not want them to do this, you should choose not
to participate in this study.
9 Could this research project be stopped unexpectedly?
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We do not expect this research project to stop unexpectedly. However, if this situation arose
the research team would communicate with you.
10 What happens when the research project ends?
Transcribed anonymised interviews will be analysed by the research team using the
Normalisation Process Theory Framework. Please let us know if you would like a summary
of the results of this study shared with you by endorsing/ ticking the Yes response option on
the Consent Form
Part 2 How is the research project being conducted?
11 What will happen to information about me?
By signing the consent form you consent to the relevant research staff collecting and using
information about you for the research project. Any information obtained for the purpose of
this research project can identify you will be treated as confidential and securely stored. It
will be disclosed only with your permission, or as required by law.
Your demographic information (e.g. sex, profession, duration of employment) and your
contributions in the interview regarding your experience of psychosocial interventions and
CBTp will be collected. The interview will be audio-recorded. The recording and your
demographic information will be stored on a password-protected computer at the University
of Glasgow. Any paper files will also be stored securely at the University of Glasgow. The
audio recordings will only be accessible by select members of the research team for the
purpose of coding the specific responses of participants. After the completion of the study
codings will be entered in a re-identifiable (i.e., coded) format into a databank, which will be
stored securely at the University of Glasgow.
All of the investigators listed on this Participant Information Sheet/ Consent Form will have
access to the de-identified study data (i.e., demographic information, interview codings).
Your information will only be used for the purpose of this research project, and it will only be
disclosed with your permission, except as required by law.
It is anticipated that the results of this research project will be published and/or presented in a
variety of forums. In any publication and/or presentation, information will be provided in
such a way that you cannot be identified, except with your permission. Information that is
published from this study will only include summary information that describes the whole
group of participants in this study and not to any individual participant. We will use
quotations taken directly from interviews. However, you or your service and its users will not
be identifiable based on these quotations.
12 Who is organising and funding the research?
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This research project is being conducted by University of Glasgow Doctorate in Clinical
Psychology training programme. This study will contribute towards an educational
qualification (Doctor of Clinical Psychology; DClinpsy) of the student, Mr Xanidis.
Therefore, the findings of this study would be included in Mr Xanidis’ thesis as well as
publications. Investigators for the study are:
1. Mr Nikos Xanidis (email: [email protected])
2. Professor Andrew Gumley (email: [email protected]; tel:
01412113939
The sponsor of this study is NHS AA (Research and Development Service). No financial
benefits are expected to arise from the conduct of the research.
13 Who has reviewed the research project?
The research has been reviewed by University of Glasgow Doctorate in Clinical Psychology
and NHS Ayrshire and Arran Research and Development Department. Professor Rory
O’Connor who is not involved in the study but has reviewed the study is the independent
reviewer. The research has been approved by the University of Glasgow College of Medical,
Veterinary and Life Sciences Ethics Committee.
14 Can I speak to someone who is not involved in the study?
Yes, you can speak to Professor Rory O’Connor who is not involved in the study but has
reviewed the study. He can answer questions or give advice about participating in this study.
His telephone number is 0141 211 3927.
15 What will happen if there is a problem or if I want to make a complaint?
If you have any concerns about the study or the way it is conducted or if you want to
complain about any aspect of this study, please contact Prof. Andrew Gumley, Institute of
Health and Wellbeing, Gartnavel Royal Hospital, 1st Floor, Admin Building, University of
Glasgow, Glasgow G12 0XH, or the Research & Development Service, NHS Ayrshire &
Arran on 01563 825850. The normal NHS complaint mechanisms will also be available to
you.
Thank you for reading this Participant Information Sheet
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Appendix 2.8: Interview Topic Guide
What Questions
Grand tour
question • I am really interested to hear about your experience of supporting
people with psychosis from your role a
psychiatrist/psychologist/OT/therapist?
• What a day to day work with people with psychosis involve?
• Do you have an example?
Opening
discussion:
Introducing
Psychosocial
interventions
• How would you describe your experiences of psychosocial
interventions being offered to service users with psychosis?
• I am interested to know more about your psychosocial practice, and
especially ways that you support people with psychosis stay well?
Introducing
CBTp • What are your views of CBT for psychosis?
• I am interested to hear your views of CBT as a treatment option for
people with psychosis.
• How is CBTp different compare to other interventions for psychosis?
• How would you describe your experiences of CBTp being
offered/delivered?
• What are your experiences of referring people for CBTp?
• What are your experiences of witnessing CBTp? How people with
psychosis respond?
• What are the advantages of having CBTp?
• What are the challenges /disadvantages of CBTp?
Do you think that CBTp should be implemented more widely? /What are the
challenges of implementing CBTp more widely?
If yes/What would need to change?
If not Why not?
• What would help you as a psychiatrist/ot/nurse/therapist/psychologist
to successfully implement/use/refer CBTp?
• How do you think OT/Psychology/ Psychiatry in Ayrshire can be
involved with CBTp or PSI implementation? What are the skills that
you could be use to achieve that?
• What would keep you involved/committed?
• What do you think the role of OT/psychiatry/nursing/ psychology in
Ayrshire can be in the implementation of CBTp?
Overall and
concluding
thoughts
Thinking of CBTp overall and thinking ahead how would you know it’s
worth the effort?
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Appendix 2.9: A list of the overarching themes
Perceived barriers to engagement
Severity of symptoms
Chronicity of symptoms
Better outcomes with early intervention
Insight
Comorbidity
Medication side effects
Drop outs
Potential of increase in distress
Life style factors
Peer influences
Family involvement/support
Social deprivation
Contextual barriers to implementation
Lack of resources
Waiting times
Referral criteria/ suitability of intervention
Focus on outcomes
Rejected referrals frustration
Lack of referrals for CBTp
Lack of documented outcomes
Clinical priorities
medical model
Meeting targets
Professionals’ roles
Demand for other clinical presentations
Optimisation of the implementation
Importance of managerial support (allocated time, supervision)
Raising awareness around CBTp
Change in Culture
More flexibility / Outreach work
Supporting staff with speciliast interest
Having people with specialist interest (clinical leadership)
Referral pathway protocol (clinical leadership)
Importance of measuring long term outcomes
Importance of supervision
Having the same framework-Integration of psychology in teams-
Need for more training in CBTp
Service user involvement
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Positive attitudes towards CBTp
Using CBTp to improve engagement
Using CBTp to liaise with staff
Ways to support implementation
CBT and self-management
CBT and quality of life
CBT formulation
CBTp shared responsibility
CBTp easy to understand
Expectations of implementing CBTp
Reduction in admission
Reduction in medication
Reduction in relapse severity
Quality of life
Self report measures
Feedback from family and carers
Less referrals to crisis teams
Direct feedback from service users
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Appendix 2.10: Consent Form
Participant Consent Form
CONSENT FORM
Identification Number for this study:
DISCO: Discovering Implementation in health Services of COgnitive Behaviour
Therapy for psychosis
Chief Investigator: Professor Andrew Gumley
Name of Researcher: Mr Nikos Xanidis
Please initial box
1. I confirm that I understand the nature of the study proposed, having read and
understood the information sheet provided, DISCO Participant Information
Sheet Version 1.3, 13th of November 2017. I have had opportunity to ask
questions and am satisfied with the answers I received.
2. I understand that my participation is voluntary, and that I am free to withdraw
from the study at any time. Should I wish to withdraw, I understand that I can
do so without giving reason, and without my employment being affected.
3. I agree to take part in the study.
4. I agree that you may audio tape sessions as required.
5. I agree that fully anonymized quotations may be used in publications
and other materials arising from the study
6. I would like to receive a copy of the study results.
Subject Name Date Signature
……………………… … / … / …… …………………….
Researcher Date Signature
……………………… … / … / …… …………………….
1 copy for participant; 1 copy for researcher
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Appendix 2.11: Sample of thematic analysis coding
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